Pot, kettle, moo.
There’s uproar amongst opponents of single payer health care over a recent survey published in the Annals of Internal Medicine (letters section, thus avoiding peer review) suggesting that a majority of doctors (59%) support “universal health care.” Critics point out, rightly, that the survey (which consisted of two relatively straightforward questions and unknown accompanying material) was sent to members of the AMA, which is pro-universal health care but not pro-single payer and perhaps not a representative sample of physicians across the board, and that just over half of the surveys sent out were returned, which opens the door for serious selection / response bias. And certainly, the media coverage seems a bit much.
The authors address some of the methodological concerns in a similar study conducted five years ago (opens in pdf format), to which this survey is intended as a follow-up. There’s no mention in the current one of whether the trend towards more support is significant or even amenable to statistical analysis, but the clear implication of publication is that it is meaningful.
More interesting to me than the merits of the survey itself (my opinion is that it’s relatively worthless) are some of the comments by critics that the data is untrustworthy simply because its author, Aaron Carroll, is a member of Physicians for a National Health Program. As best I can tell, Catron goes so far as to lie about Carroll’s credentials.
The lead author of this “survey” is Aaron E. Carroll, a single-payer zealot on the Board of the activist group “Physicians for a National Health Program.” This guy routinely produces “studies” and “surveys” that somehow always show that Americans in general and the medical community in particular want government-run health care.
I will note that a pubmed search for “carroll ae” turned up only the two surveys already mentioned, and Catron only links to a pro-single payer op-ed written for an Indiana newspaper.
Greg Scandlen, who appears to be much more reasonable, still manages to startle.
The letter was written by Aaron Carroll, MD and Ronald Ackerman, MD, both of the Indiana University School of Medicine. I don’t know about Dr. Ackerman, but Dr. Carroll is a member of the board of directors of Physicians for a National Health Program (PNHP), so is hardly an unbiased researcher. Interestingly, the Annals requires the disclosure of financial conflicts of interest, but not political conflicts or biases.
As a fan of overcoming bias of all types, I wholeheartedly support the idea that scientists should try to perform research which disproves their own hypotheses, and I think the restriction of conflict of interest disclosure to direct financial matters absurd (”Dr. Blue discloses that his sense of self worth depends on the positive results presented in this study”) . I doubt that we could trust many papers if all potential conflicts were disqualifying — how many papers in support of HSAs are written by people who don’t support HSAs? Pragmatically, it’s hard enough to get people to disclose their financial conflicts, and it seems that disclosure of political conflicts or personal biases is a nebulous concept that would be impossible to enforce. What biases are relevant? (”Ok, well he’s not really for PNHP, but he did vote for Clinton in the democratic primary”). Interestingly, in papers I could find on pubmed, Scandlen is listed as affiliated with “Consumers for Health Care Choices,” but no disclosure of his own personal biases or political views are made explicit.
Update: Don McCanne of the PNHP comments on Healthcare BS to say that (1) the article was peer reviewed (don’t know the Annals letter policy), and (2) that the doctors surveyed were selected from AMA masterfile, not member file.
A moot point which I tried to make on David Catron’s site (but he tends not to carry inconvenient information) is what other national surveys have been done on this issue. It is clearly important what physicians think and in the absence of other data then this is at least a reasonable attempt.
Comment by Marc Brown — April 4, 2008 @ 4:02 am
Hi Marc. Other surveys would be useful in interpreting this one (informing priors, say), but its problems remain. I don’t think it is particularly important what physicians think (except for the rhetorical value among the unsuspecting public), since for the most part they are trained neither as economists nor health policy experts.
Comment by alexa-blue — April 4, 2008 @ 6:34 am
“I don’t think it is particularly important what physicians think… ”
Well, that’s a rather elitist view. I don’t think that the physicians are quite the sheep you expect them to be. Look at other fields with shortages (eg. nursing) and tell me if you think nurses (who are, as an overwhelming majority, not economists nor health policy experts) opinions didn’t matter when policy decisions affected their work.
Comment by Rich — April 4, 2008 @ 8:41 am
Hi! The point isn’t that biases necessarily discredit research, but that the research should always be evaluated on its merits — regardless of underlying bias. But that also means complete disclosure of the methods employed. In this case the results were startling and the methods were suspect, so the bias was important to know.
Me? I am happy to report that I am an advocate for freedom in medicine and all other aspects of our lives. But I also try hard to be honest in my views and my methods.
Greg Scandlen
Comment by Greg Scanden — April 4, 2008 @ 9:14 am
Rich — I don’t deny being an elitist, but I’m not sure that this particular post is a great example of it (quite the opposite, I think it’s elitist to assign physicians’ views special weight in debates about health policy, simply because they are highly educated and work in a related field). Having been through the part of medical training I have to pay for I feel I know a bit about what they teach, and it’s not policy or economics. It doesn’t mean I’m a sheep, but it doesn’t make me any better qualified than the general educated popluation to comment on those matters. It’s possible that having more experience working with patients or running a practice will lead to more/better insight, but I think that’s highly unlikely to be generally true (in part because I so distrust anecdotal evidence, which is what people accumulate in residency / work, I’m tempted to think that physicians might be less reliable than age/education matched controls). I’m not sure what you mean with respect to nursing, etc.
Greg — Thanks for your response, and I don’t disagree. I would prefer to have had some indication of Carroll’s PNHP affiliation in the article.
Comment by alexa-blue — April 4, 2008 @ 5:02 pm
Alexa - What I mean by nursing is that nurses are striking, demanding grater pay and benefits in many localities. There is a general nursing shortage, which is not due to the feelings, conclusions, or studies done by economists or policy wonks, but because the nurses themselves (or those that might otherwise be nurses, but are not) are making choices not to participate.
What is elitist it to presume that a group of individuals, each of which is affected directly by policies, legistlation, etc., will not alter their behavior in response to said policies/legislation/whatever, but will just “go along” like sheep to the slaughterhouse.
Sure, you can conclude that what physicians “think” is not important as the debate goes on, (presumably because they are not economists) and then scratch your head when the policy wonks have delivered the golden fleece of healthcare systems, but cannot find any providers to staff it. At that point, you will certainly think that the physicians’ (or would-be physicians’) opinions on the matter have some relevance.
Analagously, when you are seeing patients and treating them, they will have feelings and opinions about the care and treatment you offer. Do you think their opinions are irrelevant, since they are not trained as physicians/nurses/pharmacologists/epidemiologists?
Comment by Rich — April 6, 2008 @ 12:38 pm
The relationship between government and physician is not the same as the relationship between physician and patient (the correct analogy would be government and citizen, or physician and medical assistant). Anyways, we’re talking past each other to some degree. My point is that physicians are not trained in policy and their opinions on it are not special (to be more precise/dorky, if you’re a lay person looking to judge an opinion on health policy matters, possession of an MD carries a very low positive likelihood ratio as an indicator of reliability, compared to a PHD in econ or health policy).
As to what you are saying, I agree that it’s better to have physicians than to not have physicians, and to have physicians you have to pay them utiles to do what they do. To do this, I suppose you can use either dollars or job satisfaction units (you’ll probably have to use both), and if you don’t pay them enough they’ll probably quit. On the whole, I think that the marginal job satisfaction disutility of working in a (free market)(single payer) health care system is likely to be fairly small, and there’s no reason that the costs couldn’t be balanced by more dollars payment.
Of course, I’m not convinced that having large numbers of phsyicians (and high quality applicants) choose other fields will be bad for patients in the long run, since they aren’t going to be replaced by nothing, they’re going to be replaced by the next best applicant/physician who isn’t dissuaded by not making enough dollars to enter a healthcare system which smart economists have determined delivers the best bang for the buck for the patient, and wouldn’t have gotten a position otherwise. Isn’t that who we want to be our doctors anyways? Alternatively, we could just get rid of licensure.
Comment by alexa-blue — April 7, 2008 @ 10:34 am