Saturday, July 28, 2018

NYT Very Surprised That "A Fear of Lawsuits Really Does Seem to Result in Extra Medical Tests"

Defensive Medicine: Evidence from Military Immunity. Michael D. Frakes, Jonathan Gruber. NBER Working Paper No. 24846, July 2018.

Abstract: We estimate the extent of defensive medicine by physicians, embracing the no-liability counterfactual made possible by the structure of liability rules in the Military Heath System. Active-duty patients seeking treatment from military facilities cannot sue for harms resulting from negligent care, while protections are provided to dependents treated at military facilities and to all patients—active-duty or not—that receive care from civilian facilities. Drawing on this variation and exploiting exogenous shocks to care location choices stemming from base-hospital closures, we find suggestive evidence that liability immunity reduces inpatient spending by 5% with no measurable negative effect on patient outcomes.

A Fear of Lawsuits Really Does Seem to Result in Extra Medical Tests. By Margot Sanger-Katz
Doctors are known for complaining about how the malpractice system adds costs. But it has been hard to prove, until now.
The New York Times, July 23, 2018

Back in 2010, Tom Price, then a congressman, said he knew the chief reason health care cost so much: “Defensive medicine” was costing the United States $650 billion per year — about 26 percent of every dollar spent.

The widely dismissed estimate from Dr. Price, an orthopedic surgeon who went on to become President Trump’s health and human services secretary before resigning last fall, was memorable for its magnitude.

But American doctors often rail against the country’s medical malpractice system, which they say forces them to order unnecessary tests and procedures to protect themselves if a patient sues them. Some prominent health economists, including those at the Congressional Budget Office, have tended to play down such costs, arguing that medical practice is not too warped by fear of lawsuits. But the question has proved difficult to study, since patients nearly everywhere can sue. Without a control group, it’s hard to know how differently doctors might act if they were less worried about liability.

Researchers from Duke and M.I.T. have found a pocket of America that is different, and they now offer what is perhaps the most precise estimate of how much defensive medicine matters, at least for care in the hospital. They found that the possibility of a lawsuit increased the intensity of health care that patients received in the hospital by about 5 percent — and that those patients who got the extra care were no better off.

“There is defensive medicine,” said Jonathan Gruber, a health economist at M.I.T. and an author of the paper, which was published in draft form Monday by the National Bureau of Economic Research.  “But that defensive medicine is not explaining a large share of what’s driving U.S. health care costs.”

Mr. Gruber and Michael D. Frakes, a Duke economist and lawyer, looked at the health care system for active-duty members of the military. Under longstanding law, such patients get access to a government health care system but are barred from suing government doctors and hospitals for malpractice. Their family members can also use the military hospitals, but they can sue for malpractice if they wish.

Their study looked at what happened to the hospital care that military members received when a base closing forced them to use their benefits in civilian hospitals, where it was possible to sue. Spending on their health care increased, particularly on extra diagnostic tests.

They also found that, even within the military hospitals, family members who could sue tended to get more tests than those who could not.

Previous research has primarily looked at the effects of smaller legal reforms, like state caps on the awards that malpractice victims can collect in court. Those studies showed some declines in medical spending related to the policies. But they tended to be small, and yearly variation in medical spending made it difficult to be sure how much of the difference was  because of the legal change.

“They did a nice job of finding a population of patients who are being treated by doctors who didn’t have any liability,” said Mark McClellan, the director of the Duke-Margolis Center for Health Policy. Dr. McClellan was a top health official in the George W. Bush administration, which pushed for national liability caps.

The paper’s focus on the hospital allowed the researchers to have a lot of precision in their measurements. But it means they didn’t capture all the places where defensive medicine might occur. It’s possible, for example, that liability concerns cause treatment to rise by more than 5 percent for emergency room patients who go home the same day — or not at all in a typical office visit.

Mr. Frakes and Mr. Gruber examined a large number of quality indicators to determine whether the doctors who practiced less intense medicine on their military patients were somehow cutting corners.  Each measure differed, and there were some places where harm couldn’t be ruled out, but they found no place where the quality of care in the military hospital appeared to clearly be worse.  That finding suggests that, when doctors do extra treatment or testing to avoid liability, they are not necessarily taking extra steps that make their patients any healthier.

“It suggests that physicians change their behavior in response to liability considerations, but they don’t do it in a very calibrated way,” said Michelle Mello, a professor of law and health policy at Stanford, who has studied medical malpractice. “They tend to make a lot of changes that don’t result in better patient care.”

In the federal government and in states, there are frequent proposals to limit medical liability, but there have been no serious efforts to eliminate medical malpractice rights altogether. Mr. Gruber said the paper’s estimates were best viewed as a kind of ceiling for the effects of more realistic reforms.

Any law that limits the cases where patients can sue, or the amount of money they can collect, is likely to lower medical use  in the hospital by less than the 5 percent they measured in their study.

Amitabh Chandra, a health economist at Harvard, said the best policies needed to lower the burden on physicians while still generating “social value.” He said that continued research on the relationship between malpractice pressure and health care quality was important as different approaches were tested.

The most popular state action has been to impose caps on monetary damages. In the paper, the authors suggest different types of changes to malpractice policy, including one in which doctors would be shielded from liability if they adhered to common standards of care. Ms. Mello suggested studying a system in which administrative courts, instead of juries, determined liability and damages.

Other possible approaches haven’t been tried, like a system used for childhood vaccines, in which patients are paid if they are harmed by medical care, regardless of fault.

“Policymakers have only experimented with a limited set of types of reforms to date,” Mr. Frakes said. “We haven’t experimented a lot with more structural reforms to the system.”

Margot Sanger-Katz is a domestic correspondent and writes about health care for The Upshot. She was previously a reporter at National Journal and The Concord Monitor and an editor at Legal Affairs and the Yale Alumni Magazine. @sangerkatz • Facebook

A version of this article appears in print on July 24, 2018, on Page B4 of the New York edition with the headline: Doctors’ Fear of Lawsuits May Hit Patients in the Wallet, Study Hints

Cognitive neuroscience of person identification: Comparing the processes by which people are identified through face & voice, find that face recognition accuracy suffers little or no cost with increases in set size; voice recognition accuracy declines markedly beyond a handful of possibilities

The cognitive neuroscience of person identification. Irving Biederman et al. Neuropsychologia, Volume 116, Part B, 31 July 2018, Pages 205-214.

•    The processes by which people are identified through face and voice are compared.
•    Face recognition accuracy suffers little or no cost with increases in set size.
•    Voice recognition accuracy declines markedly beyond a handful of possibilities.
•    The deficit in congenital phonagnosia need not be perceptual.
•    Face and voice recognition abilities are uncorrelated.

Abstract: We compare and contrast five differences between person identification by voice and face. 1. There is little or no cost when a familiar face is to be recognized from an unrestricted set of possible faces, even at Rapid Serial Visual Presentation (RSVP) rates, but the accuracy of familiar voice recognition declines precipitously when the set of possible speakers is increased from one to a mere handful. 2. Whereas deficits in face recognition are typically perceptual in origin, those with normal perception of voices can manifest severe deficits in their identification. 3. Congenital prosopagnosics (CPros) and congenital phonagnosics (CPhon) are generally unable to imagine familiar faces and voices, respectively. Only in CPros, however, is this deficit a manifestation of a general inability to form visual images of any kind. CPhons report no deficit in imaging non-voice sounds. 4. The prevalence of CPhons of 3.2% is somewhat higher than the reported prevalence of approximately 2.0% for CPros in the population. There is evidence that CPhon represents a distinct condition statistically and not just normal variation. 5. Face and voice recognition proficiency are uncorrelated rather than reflecting limitations of a general capacity for person individuation.

Keywords: Voice recognition, Phonagnosia, Face recognition, Prosopagnosia, Face imagination, Voice imagination

Trigger warnings may inadvertently undermine some aspects of emotional resilience: They increase peoples' perceived emotional vulnerability to trauma, the belief that trauma survivors are vulnerable, & increase anxiety to written material perceived as harmful

Trigger warning: Empirical evidence ahead. Benjamin W.Bellet, Payton J.Jones, Richard J. McNally. Journal of Behavior Therapy and Experimental Psychiatry,

•    Trigger warnings increase peoples' perceived emotional vulnerability to trauma.
•    Trigger warnings increase peoples' belief that trauma survivors are vulnerable.
•    Trigger warnings increase anxiety to written material perceived as harmful.


Background and objectives: Trigger warnings notify people of the distress that written, audiovisual, or other material may evoke, and were initially used to provide for the needs of those with posttraumatic stress disorder (PTSD). Since their inception, trigger warnings have become more widely applied throughout contemporary culture, sparking intense controversy in academia and beyond. Some argue that they empower vulnerable individuals by allowing them to psychologically prepare for or avoid disturbing content, whereas others argue that such warnings undermine resilience to stress and increase vulnerability to psychopathology while constraining academic freedom. The objective of our experiment was to investigate the psychological effects of issuing trigger warnings.

Methods: We randomly assigned online participants to receive (n = 133) or not receive (n = 137) trigger warnings prior to reading literary passages that varied in potentially disturbing content.

Results: Participants in the trigger warning group believed themselves and people in general to be more emotionally vulnerable if they were to experience trauma. Participants receiving warnings reported greater anxiety in response to reading potentially distressing passages, but only if they believed that words can cause harm. Warnings did not affect participants' implicit self-identification as vulnerable, or subsequent anxiety response to less distressing content.

Limitations: The sample included only non-traumatized participants; the observed effects may differ for a traumatized population.

Conclusions: Trigger warnings may inadvertently undermine some aspects of emotional resilience. Further research is needed on the generalizability of our findings, especially to collegiate populations and to those with trauma histories.

When comparing ideal partner preferences, continually-coupled individuals rated Warmth/Trustworthiness and Vitality lower than newly-coupled individuals: Coupled individuals adjust their ideal mate preferences according to their actual partner

Coupled individuals adjust their ideal mate preferences according to their actual partner. Radka Kučerová, Zsófia Csajbók, Jan Havlíček. Personality and Individual Differences, Volume 135, 1 December 2018, Pages 248-257.

Abstract: It has been suggested that coupled individuals tend to adjust their ideal partner preferences according to their actual partner. In Study 1, we developed a mate preference trait-list and found a four-factor structure (Physical attractiveness, Status/Resources, Vitality, and Warmth/Trustworthiness), which we confirmed in Study 2. In Study 3, we compared ideal and actual partner preferences in continually-coupled and newly-coupled individuals. Ideal partner preferences were recorded in continually-coupled participants while in the relationship and in single participants before they established a relationship. Results showed that discrepancy between ideal and actual partner evaluations was lower in continually-coupled than in newly-coupled individuals when computing Manhattan distance between them. When comparing ideal partner preferences, continually-coupled individuals rated Warmth/Trustworthiness and Vitality lower than newly-coupled individuals. No difference between continually-coupled and newly-coupled individuals was found in their actual partner evaluations. Our results indicate that relationship status significantly affects ideal partner preferences.

Against the widespread belief that modern-day loneliness is inevitable, negative, and universal, loneliness is relatively recent invention, dating from around 1800 that needs to be understood firstly as an “emotion cluster” composed of a variety of affective states

This “Modern Epidemic”: Loneliness as an Emotion Cluster and a Neglected Subject in the History of Emotions. Fay Bound Alberti. Emotion Review,

Abstract: Loneliness is one of the most neglected aspects of emotion history, despite claims that the 21st century is the loneliest ever. This article argues against the widespread belief that modern-day loneliness is inevitable, negative, and universal. Looking at its language and etymology, it suggests that loneliness needs to be understood firstly as an “emotion cluster” composed of a variety of affective states, and secondly as a relatively recent invention, dating from around 1800. Loneliness can be positive, and as much a part of the body as the mind. Using a longue durée approach, I argue that we cannot understand loneliness as a “modern epidemic” without considering its history, its meanings, its practice, and its links with the body.

Keywords: emotion, history, loneliness, longue durée