Prescribing cheap

A while ago, I received a letter from the Social Insurance Institution (the government agency responsible for the Finnish social security programs including subsidizing drug prices) that summarizes some key figures regarding my prescriptions from year 2014. (It’s the very first such letter by the way: I’ve been practicing medicine for a little more than a year now!)


I was surprised to find that my average prescription cost was only around half of the Finnish average. Why might that be?

The most obvious explanation is that I work in primary care, not in, say, oncology or rheumatology where some useful drugs just happen to be quite expensive. But that’s unlikely to be the whole story: when compared to other non-specialized doctors my figure was still 42 % lower.

I believe one reason is that my basic toolkit of drugs includes molecules such as metformin, ibuprofen, ramipril, omeprazole, escitalopram and paracetamol – tried-and-true medications whose patents have expired. The market is flooding with “me-too drugs”: slight modifications of existing molecules that are heavily advertised and expensive but offer few benefits over the originals they are trying to replace. In these cases, going for the cheaper alternative will not hurt the patient a bit: they (and the national economy) will get the same benefit without wasting any money.

In the case of equally safe and effective medications where the more expensive one has some minor edge over the cheaper one – such as the newer oral anticoagulants which, unlike the older warfarin, do not require as extensive laboratory monitoring – I lay out the facts, and often the patient opts for the more affordable option.

Prosperity Without Growth: ”It’s capitalism, Jim. But not as we know it”

I’ve had serious doubts about the degrowth movement in the past, not because I wouldn’t sympathize with their concerns over the globe but because I used to think their views were based on intentional misunderstanding of economics.

After reading Prosperity Without Growth: Economics for a Finite Planet by Tim Jackson, I’m not so sure anymore.

Jackson, an economist himself, does not claim that economic growth is evil, on the contrary it is still very much needed for the poorest countries (I would also argue it is needed for poor populations in prosperous industrial countries).

But because of diminishing marginal utility more growth in the developed world will not increase wellbeing much; Jackson argues it may even turn against it’s purpose. When you’ve been starving, eating that first sandwich will be blissful, the second great, the third alright and the fourth will only make you fat.

What I learned in my first Economics class is that infinite growth and finite resources need not be conflicting ideas because they can be decoupled. While resources are being used ever more efficiently, Jackson arguments that a true decoupling has never taken place, nor will it in the foreseeable future.

Another reason why even the most sceptical reader should not dismiss zero-growth theories offhand is that even without any environmental or moral considerations, zero growth might be inevitable at some point due to rising prices of commodities etc. Better to be prepared?

Jackson’s final chapter offers some ideas for achieving sustainable prosperity which are easy to agree with. The more you dislike degrowth buffs, the more you should read this book. 4 out of 5.

A dead malicious move against undocumented migrants

The piece of news is one week old already but still makes my blood boil.

In the final days of the sitting parliament, MP Kari Rajamäki of the Social Democratic Party pulled a dirty trick to block a law proposal that would have given undocumented children and pregnant women access to public healthcare.

The law had been well prepared by the National Institute of Health and Welfare and backed by the social and health committee as well as nearly all MPs. In other words, it was certain to pass – if Rajamäki had not utilized a little-known loophole in the legislative process to postpone the hearing beyond the current parliament’s term, in effect cancelling it.

Whatever the encyclopedic definition of a jerk is, ”someone that deliberately sabotages the right of poor women and children to receive care” must come close. 

I didn’t know stuff like this was even possible in a Western democracy. Rajamäki has been scolded by next to everyone – including members of his own party – for his disinterest of human rights and his mockery of the democratic process. He conveniently dodges all consequences – by retiring.

Well, the law will pass the next time around. Time to elect some more responsible people onboard.

The Sacred Drunken Cow

Look at this graph and tell me retail sales don't matter for alcohol consumption.

Look at this graph and tell me retail sales don’t matter for alcohol consumption (source).

Let’s face it: The Finns are in denial about alcohol and public health. Arguments supported by data are regularly dismissed in public discussion and downvoted on internet forums: most recently in the context of the Centre Party’s suggestion that the sale of mid-strength beer be restricted to liqueur stores.

It has been estimated that this very measure would cut alcohol-related deaths by 350 a year.

When mid-strength beer arrived in Swedish and Finnish grocery stores in the 1960s, alcohol consumption and associated illness exploded. When Sweden later reversed this policy, it was a public health victory (pdf).

Unsurprisingly, the brewing industry has cried out against sale restrictions, but so have many citizens. It’s like a fundamental civil right was at stake.

The opponents’ fears include…

  • increase in total alcohol consumption should the Finns begin to visit liqueur stores more frequently (unfounded; empirical evidence says the opposite)
  • increase in imported alcohol (unlikely, since 90% of Finns live within a few kilometers of a liqueur store, but even if realized this would likely be far outweighed by the positive effects)
  • unemployment in breweries and retail trade (probably some, but again – what is a few lost jobs compared to 350 people killed a year, not to mention other costs to society and families)
  • paternalism, slippery slope, prohibition, freedom of speech, #byroslavia, #sovietfinland.

I’m not pushing for prohibition, I like mid-strength beer as much as the other guy. It’s just that I can walk an extra 100 m to get it if that is the price of a healthier nation.

Keppana Alkoon prkl!

The Emperor of All Maladies

The_Emperor_of_all_MaladiesIn my read books list, I’ve begun to mark with a () any that I would specifically recommend to people in the healthcare sector. Siddhartha Mukherjee’s The Emperor of All Maladies clearly deserves that badge.

The book, as the subtitle has it, is “a biography of cancer”. From its earliest occurrences in historical texts to recent breakthroughs in science and therapy, Mukherjee tracks the ”life and times” of malignant disease. The history of oncology is fascinatingly intertwined with the development of healthcare in general: antiseptics, surgery, pharmacology, the whole concept of preventive medicine, the discovery of AIDS and genetics…

But the scope of the book is as much societal as it is biomedical. It turns out, for example, that in the 60s and 70s there were hugely influential lobbying groups against cancer in the U.S. – the reasoning being that ”if we can build an atomic bomb and put a man to the moon, we sure can cure cancer”. Science is never only about science, it’s also about PR and being able to sell one’s story to obtain funding.

Mukherjee portrays in a lively way the individuals who played key roles in discovery of oncological therapies. Many of them ring a bell, having lent their names to syndromes or surgical instruments. And many had colorful, quirky careers. Take William Halsted for example, the guy who mastered radical cancer surgery while high on cocaine.

But the writer also makes it clear that science is more about teamwork than individual accomplishments. The ”genii” of oncology also sometimes turned out to be the biggest brakes on the field’s development, having so fallen in love with their theories as to try to prevent any attempts to prove otherwise. The most inspiring cancer scientists opened new lines of thought for the path dependent science and thus laid way to even greater discoveries than their own.

The chapters that describe the clinical trials and medical innovations are actually the less interesting parts of the book (although well-written and not too technical, they still feel more like the stuff of medical textbooks). What I liked especially is when Mukherjee describes the societal and philosophical impact of cancer and cancer research.

Every chapter opens with 2 or 3 quotes that serve to convey the zeitgeist of the past decades’ cancer scientists. It is sobering to realize how quickly attitudes and dogmas have changed. Among other things, The Emperor of All Maladies is a study of medical misconceptions, from the generations of doctors who followed the Hippocratic and Galenic humoral theories without daring to object to these authorities to the 20th-century surgeons who insisted on overly radical, disfiguring operations and even opposed adjuvant chemotherapies before the concept of staging was developed and the evidence for chemo’s benefits too clear to ignore anymore.

All in all, the history of cancer makes up for an unexpectedly good story. The disease first enters history as a vague unknown threat and during the centuries of research becomes an almost anthropomorphic enemy against whom ”wars” are waged. For a serious scientist whose publication history includes Nature and NEJM, Mukherjee’s writing is sparkling. Consider this sentence for instance:

Society and illness often encounter each other in parallel mirrors, each holding up a Rorschach test for the other.

Anecdotes from the Mukherjee’s own practice are interwoven with historical accounts and serve to show that some dilemmas – e.g. when to abandon hopes of cure and settle for good quality palliative care – are still the same than decades ago. The author’s sometimes very personal experiences from the wards are among the most touching parts of the book.

My only grudge is non-continuity. The events covered by the book span centuries and often the story just leaps suddenly from one era and place to another. Many such transitions make sense thematically (and I can see how abandoning the strictly chronological approach might have served the structure of the book) but some of them are confusing and break the rhythm of the story.

Anyway, one of this year’s highlights for me.

Love triumphs over ignorance

That’s a pompous choice of words, but nothing summarizes better how I feel about the Finnish parliament’s decision to allow same-sex marriage today. I’m happy, happy for myself and for my gay friends to whom I know this is huge thing.

The new law is a historic one, naturally from the equality perspective but also because it was the first “popular initiative” to pass in the parliament.

The opposing front (besides quoting the Bible) has mainly expressed concern over children’s wellbeing in same-sex families. This, as peer-reviewed literature has it, is rubbish.

The Art of Thinking Clearly

The Art of Thinking Clearly is a 2011 pop-sci book by Rolf Dobelli: a catalogue of common cognitive biases that in a systematic manner cause people to act irrationally and often against their best interest. Each bias is introduced in a short chapter with a few entertaining examples and some speculation of its background in evolutionary psychology.

Health professionals are not immune to cognitive errors and the book serves as a healthy reminder about that. Among the many intellectual traps doctors can fall into is action bias: tendency to perform dramatic interventions even when watchful waiting would be better. Availability bias – e.g. overusing a diagnostic or therapeutic procedure just because it’s on top of one’s mind – is well documented, too (when all you have is a hammer… urology edition). Omission bias might manifest in failing to use lifesaving medicines for the fear of their side effects (must be particularly true in the U.S. and other countries where liability cases are easily triggered).

On the other hand, patients and caregivers alike are prone to regression to the mean. If today’s back pain is worse than ever, it is likely to improve by tomorrow for purely statistical reasons, not necessarily because you saw a doctor/chiropractor/homeopath today. Survivorship bias means a few vocal people praising the efficiency of a particular intervention may hide the fact that a thousand others used the same product without help.


The Art of Thinking Clearly
is not a scientific treatise or a psychology textbook (but readers hungry for more information will find references in the end). Despite the name, it’s not a handbook to better thinking either, more like a collection of anecdotes.

Still, the book is clever, accessible and fun (a fairly quick read, too), and will hopefully do a small favor to the world by raising awareness of the fallibility of our minds and by culling some bad argumentation.