Once a decade, I am obligated to read a book from Eric Topol. Ten years ago it was during a rotation at Georgetown where they were handing around copies of The Creative Destruction of Medicine like candy. Of course, if those books had truly been candy they would have been of the sort that quickly congeals into an inedible hard lump because nothing in The Creative Destruction… aged well.

Well this year Topol has a book out on aging, and if it weren’t for some high-profile endorsments I would not be paying it two cents. But then I saw Nassim Taleb praising its rigor and scholarliness, highlighting as an example that Topol cites multiple trials for each claim. One can hope the trials he cites actually back up the claims, and to confirm that is indeed the case I now have Super Agers on the pile. Kindle version only: physical space in our library is too precious for Topol.

Noah Smith writes about health care costs:

So overall, health care is probably now more affordable for the average American than it was in 2000 — in fact, it’s now about as affordable as it was in the early 1980s. That doesn’t mean that every type of care is more affordable, of course. But the narrative that U.S. health costs just go up and up relentlessly hasn’t reflected reality for a while now.

And he has the data to back it up, though some of it feels like playing the denominator whack-a-mole. Interesting regardless. (ᔥTyler Cowen)

Yes, investigator-initiated clinical trials take time. But rather than back-patting and boasting about how it can still be done despite the setbacks, why not propose solutions for how to speed them up? I made a few off-the-cuff suggestions but you can also find serious efforts on that front.

A major entry in the Annals of Zombie Medicine must be screening for prostate cancer in men age 70 and above. Recent events had Nassim Taleb asking whether one could detect aggressive prostate cancer early, and one could, but… Indeed, this kind of screening has been singled out as something not to do for more than a decade, and yet:

Prostate screening in men ≥70 has not reached a 50% reduction in use since the 2012 guideline release.

Meanwhile, a full one-third of adult Americans is not doing the kinds of screening that are recommended, probably because they involve poop.

Another good podcast episode: neurosurgeon Theodore Schwartz talking to Tyler Cowen. Dr Schwartz is a bigger believer in science than yours truly:

COWEN: Do you think there are areas of science, though, where the institutions are so screwed up that you don’t actually trust the product of what is coming out, and there’s some systematic bias in the ideas being generated?

SCHWARTZ: I think, yes, there’s always going to be politics involved, and we always come to any problem from a unique single perspective, and institutions are going to have their biases. Yes, that is true, but in the long run, the scientific method will figure it out, and there will be one right answer. That institution — whatever their bias is — will be proven wrong in the long run. Now, those people might be dead and won’t be able to apologize at that point.

The problem, of course, is even when the scientific method does figure something out, people still keep doing things the old way, and no, generational change does not help. Witness homeopathy, kyphoplasty, vitamin C for colds, and — more relevant to Tyler’s question — the amyloid plaque hypothesis of Alzheimer’s disease. Abandoning lobotomies was an aberration, zombie medicine is the rule.

Today in titles that trigger me: Where is the YIMBY movement for healthcare?.

YIMBY is too simplistic of a concept to be easily applied to healthcare. It relies on a single dimension — how easy is it to build housing — and any proposed policy can be easily placed on the NIMBY/YIMBY spectrum. And since everyone can agree on where a particular policy lies on that spectrum, creating alliances is easy.

No such luck for American healthcare, where there are many dimensions: accessibility of new procedures (clinical trial YIMBYism), accessibility of approved treatments (insurance YIMBYism), accessibility of healthcare providers (practitioner YIMBYism), accessibility of MDs in particular (doctor YIMBYism)… And even there it is not clear what the YIMBY-equivalent stance would be. Does clinical trial YIMBYism mean you want more trials, quicker trials, or just more drug approvals and doing away with trials entirely? If you are a doctor YIMBYist, do you want to increase the number of medical schools? Residency and fellowship slots? Enable more foreign medical graduates to enter practice? All of the above? But then how do you deal with practitioner YIMBYists, who want to do away with most doctors altogether and delegate most work to physician assistants, nurse practitioners and, at the end of the line, large language models?

There is not a single person in America who would say its healthcare system is working, and yet it is clear why there is no unified front on how to fix it.

To be clear, I quite like the ideas brought up in that leading article. The five sample issues it names — breakdown of the direct doctor/patient relationship, unclear fees for service, frequent insurance switching, no room for insurer creativity, too much money spent on end-of-life care — are spot on. ⊕ If I had to pick one thing where I would want to be a YIMBYist, it is to remove any direct influence of the federal budget on healthcare. A large pot of money leads to hypertrophy of every other part of the system which down the line lead to many of the issues above. But is that really a YIMBY attitude?But alas the issues in question are too complex to be boiled down to a YIMBY-equivalent jingo, and to emphasize that point the article has an addendum linking to a 10,000-word report on the topic which at a glance seems to be raising the right points but I couldn’t really tell you since I have a day job that doesn’t leave much time for reading 10,000-word policy papers.

(↬Ruxandra Teslo)

Today’s FT essay on the rise of the anti-vaccine movement was a miss. Instead of asking why so many people lost trust in institutions it goes straight to politics: 10 paragraphs on Germany’s AfD, no mention of whether some of the people’s concerns were valid. With that, the movement can only grow.

A one-two punch on clinical trials from Ruxandra Teslo and Willy Chertman today: first their on-point agenda for clinical trial abundance as a guest post in Slow Boring, then Ruxandra’s longer essay which has been so thoroughly research that even yours truly gets a name-check. As I noted elsewhere, every US institution has made one bade tradeoff after another in how it conducts clinical trials to the point that it’s impossible to conduct a RECOVERY trial equivalent over here. That needs to change.

A few sentences to make your blood boiling in this whopper from Noah Smith:

It’s mostly the providers overcharging you, not the middlemen.

[…] the Kaiser Family Foundation does detailed comparisons between U.S. health care spending and spending in other developed countries. And it has concluded that most of this excess spending comes from providers — from hospitals, pharma companies, doctors, nurses, tech suppliers, and so on.

The actual people charging you an arm and a leg for your care, and putting you at risk of medical bankruptcy, are the providers themselves.

Excessive prices charged by health care providers are overwhelmingly the reason why Americans’ health care costs so cripplingly much.

And to top it off:

Over at Tyler Cowen’s blog, a commenter argues that profit margins are not a good guide to the financial success of a business, and that instead one should look at return on equity (ROE). But if you look at the list of companies with the highest ROE, you see health care providers or suppliers like HCA Healthcare (272%), Cencora (234%), Abbvie (84%), Mckesson (84%), Novo Nordisk (72%), Eli Lilly (59%), Amgen (56%), IDEXX Laboratories (53%), Zoetis (46%), Novartis (44%), Edwards Lifesciences (43%), and so on.

Using “healthcare provider” to mean pharmaceutical companies is at best careless when the article you are writing is directly tied to a murder of a health insurance executive. But what really upsets me is that he is right: physicians, nurses, etc. have allowed themselves to be tied to these behemoths for the promise of what? A steadier paycheck that is less — for the time spent in school and at work — than what a mid-career IT professional earns? Sad. (↬Tyler Cowen)

On my way back from #ASH24 I’ll go back through the abstract book and check out how many cell therapy oral presentations were given by investigators from China. This is the first meeting I’ve attended since 2019 and the difference is striking. Kudos!