Clinical Conversations

Why can’t the U.S. control prescription drug pricing as they do in the U.K., where per-capita spending is less than half our level?
In a capitalist democracy, many parties — the drug companies, medical associations, consumer groups — get to lobby their points of view. Is the problem intractable, or just an exercise in chaos?
Our three guests have written a book about the problem, “The Right Price: A value-based prescription for drug costs.” And although they don’t have a definitive answer, they do offer recommendations, interesting observations, and a way forward.
Listen in and let us know what you think.
[Running time: 26 minutes]
“The Right Price” (Amazon link)
TRANSCRIPT
Joe Elia:
The US has the highest drug prices around, right? And it threatens household as well as governmental budgets. Who sets those prices? What is their basis?
You’re listening to Clinical Conversations from the NEJM Group. I’m Joe Elia and I’m here with the authors of a book that came out last year titled, “The Right Price: A Value-Based Prescription for Drug Costs.” The authors are Drs. Peter Neumann, Joshua Cohen, and Daniel Ollendorf — all of the Center for the Evaluation of Value and Risk in Health at Tufts Medical Center.
Welcome.
Well, we could quickly drown in numbers here, so let’s get some out of the way, immediately.
One is that US prescription pricing amounts of some $500 billion a year. And the other that I’d like to cite is our per capita spending on those drugs, on those prescription drugs, is at least twice that in the United Kingdom.
So, there are more numbers, but let’s get around to your book. As the book’s first author, Dr. Neumann, you’ll get the first question, but anyone’s allowed to answer at any point. So, why did you write The Right Price and what has the reaction to it been?
Dr. Peter Neumann:
Well, thanks, Joe, for having us first of all.
We wrote this book because the conversation around drug prices is very important, but it tends to focus on the level of prices, not on the value that the drugs deliver. And we thought it very important to try to orient the debate around drug value and not drug prices.
Everyone wants lower drug prices, of course, we do too, but the really critical question is what value the drugs are delivering, and how do we think about that, and what’s an acceptable price, given the value? And so far the reaction to the book, I think, has been quite positive. We’ve spoken to many audiences and had a lot of positive feedback from people. And I think, and we hope, that it’s contributing in a constructive way.
Joe Elia:
People who read medical literature often come across the acronym QALY. Can somebody explain that in 10 seconds or less?
Dr. Joshua Cohen:
Maybe I’ll take a shot at it. So, a QALY is just a life year, but we scale it to also account for health. So, are you in pain — are you functional, and so on? A “one” corresponds to the hypothetical state of being in perfect health; “zero” is the equivalent of being dead, and the rest of us are in between; closer to 1 is better.
Joe Elia:
Thanks, Josh, that was close to 10 seconds. So, somebody who’s not feeling well a lot would probably score only maybe a 0.6 out of 1 or 60 percent of 100. And so, you would say a year in that person’s life would represent 0.6 QALY’s.
Dr. Joshua Cohen:
Yeah. I mean, actually, 0.6 would be really someone in quite a bit of discomfort or you know loss of function, but yes that’s the idea. Someone who’s, you know, in very poor condition would have a number like that.
Joe Elia:
Okay. So, one organization, the Institute for Clinical and Economic Review (or as I think of it as “ICER”) gets a lot of mention. And we should mention as well that Dr. Ollendorf worked there for about a decade, I think. What is ICER and what does it do?
Dr. Daniel Ollendorf:
So, ICER in the parlance of the day is known as a health technology assessment organization. So, it does its work along the same lines that many other agencies and organizations internationally, such as NICE in England or the Canadian Agency for Drugs and Technologies in Health or CADTH in Canada, do. Essentially, it’s an organization that is focused on understanding the clinical evidence on new and emerging technologies. So, to Josh’s point, what kind of benefit…or to Peter’s point, what kind of benefit the new treatments might bring? And also, to understanding questions about the cost-effectiveness and the impact on the budget that these new technologies might bring as well.
So, really using state-of-the-art scientific techniques to understand the value equation that we talk about in the book.
What kinds of clinical benefits are being brought by the drug? How is that balanced out against the possible harms that the drug or technology might be causing? And what’s the price? And does that price align using a QALY as a measure of benefit? Does that price align with the value that the drug or technology is bringing?
Joe Elia:
Now, it’s not a government organization is it?
Dr. Daniel Ollendorf:
It is not. So, the US is a bit of an outlier in comparison to other developed nations, because we have no formal step to do this work. So, ICER does this as a private organization and so is limited only to making recommendations to patients, clinicians, payers and others about what a price — a value-based price — might look like and what the evidence is saying about a new treatment.
Joe Elia:
And as you said the UK has got this organization called NICE, but we don’t have one in the United States. And as I read your book, and as I’ve been reading through my life about the politics of medicine, I have the sense that the lobbying of the drug companies of medical organizations, et cetera, have a lot to do with the fact that ICER can’t be a governmental agency because they’ve been lobbied out of the government. Is that fair?
Dr. Daniel Ollendorf:
Yeah, well it’s a bit of an interesting history. So, in fact, one of the ironies here is that organizations like NICE are using methods that were, in fact, pioneered here in the US. So, we used to have government entities who did this work: the Office for Technology Assessment, the National Center for Health Technology. These were not formal agencies in quite the same way. They were more Congressional advisory services, but they provided a lot of this information and information on health technology to decision-makers and policymakers.
I think those early efforts were scuttled in part due to lobbying, not necessarily from the pharmaceutical industry. In fact, the medical profession was quite concerned at the time about this kind of work being done outside of the profession itself. But recently, it has been the case that lobbying from patient advocacy groups and from the pharmaceutical industry has prevented any sort of formal step like a NICE to be taken here.
Dr. Peter Neumann:
And I would add, Joe, the politics of this are quite tricky. There’s ideological opposition to the federal government playing too strong of a role in many areas including health technology assessment. And the rhetoric you often hear is that — at least from some places — we don’t want the federal government to get between doctors and patients in their ability to make their own decision. So, in addition to the lobbying, which we suggest and is real, I think we shouldn’t underestimate that just ideological opposition.
Joe Elia:
As I read your book I realized how complicated. I was telling myself things like, well, it’s not brain surgery — it’s worse!
Because trying to figure this out, increasingly these days, I’m reminded of what Rudolf Virchow, the founder of cellular pathology, said about medicine, and he said this in the 19th century. He said that medicine is a social science. And it seems to me that drug pricing is kind of a proof of that, that every piece of society has a stake in this. And because it’s a democracy it becomes less tidy than it otherwise might be.
You know, you hear things about, well, you know the price is “what the market will bear” and the realization is that the pharmaceutical, the drug companies sell stock and so they’re interested in having good value in their stock. But there’s a tradeoff between the interests of society and the medical and the pharmaceutical industry. Are we looking at a situation that’s going to continue to evolve and we’ll never solve this equation? It’s not like algebra, there’s no, there’s no X equals something at the end of the day. Could you comment on that?
Dr. Peter Neumann:
Well, we emphasize in the book how complicated the market for prescription drugs is. And in many ways it’s just a reflection of how complicated the healthcare system in the United States is with so many different players. We talk about all kinds of issues on the requirements, let’s say, on the demand side of the market. We have insurance. We have third party payers. We have this phenomenon that when a patient takes a drug and benefits other people benefit. On the supply side we have patents, we have regulation, we have many, many players in between the drug companies and the ultimate consumer, the patient, and on and on.
These complexities to some extent, of course, will always exist, but we argue in the book that we can at least help things along by providing better information to the marketplace on the value of prescription drugs by measuring value and disseminating that information. We argue that this is something that individuals and even individual payers can’t do very well by themselves, but really in our view it takes an organization like ICER, or perhaps in the future some government organization, to help things along.
Joe Elia:
Yes.
Dr. Daniel Ollendorf:
I might add in that, so we know that the Build Back Better Act, which did have some discussion of drug price reform in it, is sitting dormant in Congress. But I think what gives us some hope that something may be done to better integrate value into this conversation is that there still is a lot of interest in doing something. Whether that is a slimmed down version of Build Back Better or whether there is something that CMS will do on its own is an open question, but I think that there is still some energy and some enthusiasm. What we don’t know from the discussions is what sort of approach to drug price reform will be taken. Will it be some kind of across the board price controls or will it be a value-based approach? And we, obviously, argued for the latter.
Dr. Joshua Cohen:
You know, I think it’s important to emphasize something. You know Peter was talking about this, but you know at some level its like, “Wait a minute, why are drugs so complicated?” You know it seems like they’re different from all the other products that we buy, you know, from the trivial — we mention toothpaste in our book. We don’t have a toothpaste technology assessment agency, you know, looking at what the price of toothpaste should be or, even more important, you know less trivial products like cars and houses, and things like that. So, you know, what is it about drugs?
And what Peter said gets at that, which is on the demand side, you know, consumers are not patients, they’re not really in a position to choose drugs in the same way that they choose their toothpaste, right? There have to be a lot of other parties involved. There are clinicians, primarily, and on the supply side we can’t just have the sort of normal competition where, you know, different companies compete and bring the costs down to, or the price down to the marginal costs of production. And that’s because you have to have patent protection on these products, because they’re so easy to copy.
And so, that means that we can’t have the normal, you know, individual producers and consumers just interacting with Adam Smith’s invisible hand, and everything works out great. Instead, we have to collectively figure out what the price should be. And that gets to what you said earlier, which is this becomes a social enterprise, and that’s what we’re talking about.
Joe Elia:
Yes. In the United States we have offered a monopoly to the drug companies, a limited monopoly, for some time. And the argument that’s adduced, and that you bring forward in your book as well, is that, well, without this monopoly the drug companies have got no incentive to innovate, which I found — okay, so what would those companies do if they didn’t have that incentive? Would they go out and make lawnmowers or you know toothpaste?
Dr. Joshua Cohen:
Well, I mean, I think what would happen is that those companies, the capital that is behind them, it’s not so much that, like, the companies would decide something, but the capital would move elsewhere and you know the people with those skills would move to do something else. And so, we would not have, you know, if a lot of these medications sold at their cost, their marginal cost of production, they could be pennies a pill and you just would never get the kind of resources you need to attract all the people you need and the risk that’s involved the many years. You know there’s so many drugs that are investigated, molecules that are investigated, that then go nowhere that, you know, you just would not get anywhere near the kind of innovation that we get.
Dr. Peter Neumann:
And Josh’s point raises just a question that gets back to the title of our book, The Right Price. That you know we worry a lot about too high prices, understandably, but there also is a problem if we have too low prices. And so, the right price, again, is the value-based price. The price that we hope delivers the value to the consumer, but also provides the right incentives to be producers to innovate and to innovate for the next products.
Dr. Daniel Ollendorf:
So, to be clear the right price can be very high. So, if you have a gene therapy that cures a universally fatal disease that occurs in childhood, and you’re allowing that child to live something close to a complete life, that therapy can be very expensive. A million dollars, 2 million dollars might not be too high.
Joe Elia:
Right. And so, there are ways of determining what a price might be, and you talk a lot about those in the book, and this is where we start swimming in the big pool of numbers, if you’re so inclined. I’m not so inclined, but if there is an example that you would like to bring forward about this I’d be happy to hear it. Is there an approach that you might use to illustrate this?
Dr. Joshua Cohen:
I don’t know. I mean, let me take a shot at it, you know? We tell the story of how…in the book of how these methods came about. And they came about, you know, not because someone sat down one day and said, you know, we should do health economics and let’s start writing down the theorems that underlie that science. Instead, they were trying to solve, you know, pretty straightforward problems of the day. And those involved like, you know, hey, if we can save some lives what’s that worth?
And so, at first people were like, well, what’s a life worth? And then the limitations of asking that question became apparent because it was like, well, are you talking about saving the life of someone who’s 85 or someone who’s much younger? And what about the quality of life? It’s not just about extending life it’s about the quality of life. And then it’s like all right, well, how are we going to estimate things like, you know, an extra year of life or an improvement in, you know, freedom from pain? These are not things that you can estimate by going to the marketplace and seeing what price people place on these things, because they’re not bought and sold explicitly.
But economists came up with different ways of imputing these values by looking at decisions people make, for example, you know tradeoffs between large cars and small cars. Now, there are a lot of reasons why people buy large cars versus small cars, but one of them is implicitly that the large car has more safety. So, they are implicitly buying health there. So, that’s one approach. Or you can actually ask people, you can hypothetical, you know, if there were a pill that could extend your life by this much, you know, what would it be worth to you? So, there are different ways of doing it. They all have limitations, but that’s the basic thumbnail sketch of how the science of estimating the value of health evolved.
Joe Elia:
Well, you end your book with some recommendations, and you gave a nice definition of the QALY early on, and I think the book says let’s stick with it because it’s, if nothing else, a standard measure. Even though, sometimes, people say, well, it’s not that standard, but it’s the closest one we’ve got to a standard. Is that right?
Dr. Peter Neumann:
Well, I think, and we say this in the book, that the QALY is imperfect, it has its own challenges and problems, but it is useful as a kind of benchmark for value. And it’s a starting point, as we say in the book, the cost per QALY ratio as a measure of value is a starting point, and we think a good one, for this conversation about value. Other things may certainly enter the equation.
Dr. Daniel Ollendorf:
And it’s important to realize that all health technology assessment organizations, ICER included, think of the cost per QALY equation, the value equation, as an input into decision or recommendation making, not the sole driver. So, you need to look at the clinical evidence. You need to understand how severe the condition is and what the level of unmet need is in that condition. What’s the public health burden associated with it? So, there are lots of other deliberative and ethical aspects that go into that conversation.
Joe Elia:
And one of your recommendations, and you are all fans of ICER or something that would evolve from ICER, you say that ICER should be more transparent in its analyses. So, in other words they should be giving people the wherewithal to reproduce the calculations that they make.
Dr. Joshua Cohen:
Yes. So, of course these issues are extremely controversial and the only way that we can, I think that we can really make progress towards some sort of consensus on what the price of a particular therapy should be is if at least we can agree on the analysis, the facts, so to speak. And the best way to do that is to lay bare what we’re doing. So, when ICER or another health technology assessment organization does their analysis the best way that they can convey what they’ve done is to say, look, here’s our model, here’s our computer code. You can look at it. You can change it and see how different assumptions affect the answer. Then, at least, we can argue about what the right assumption should be rather than, you know, just kind of not being able to reach any consensus. Because I can’t really tell what you’re doing and we’re stuck.
Dr. Daniel Ollendorf:
We also argue that everyone in the ecosystem needs to do this. So, a lot of these analyses are sponsored by pharmaceutical companies and they need to be open with their models too.
Joe Elia:
It’s a good book, I have to say. This is not a book review, but I’ve learned a lot reading it and I think that anyone who’s going to be a student of drug prices or clinicians who are taking a course in it would benefit from your book and I want to congratulate you. Is there a question that I have not asked that you wish I had?
Dr. Joshua Cohen:
You know, I think one thing that would be helpful is just even a simple explanation of what is a cost-effectiveness ratio, because, I think, especially you said that young clinicians are your audience. And so, you know, cost-effective ratio sounds really technical, but what a cost-effectiveness ratio is, is it’s the incremental cost per unit of benefit. Even that sounds complicated, but it’s really just a price. So, you know, if I go out and buy a gallon of milk, you know, 4 dollars per gallon of milk, the cost per unit of good thing, the milk, that is better than 5 dollars per gallon of milk.
So, we want low ratios, that’s good, and higher ratios are not as favorable. And to determine whether something…whether we’re paying too much for something we look at the ratio and we say, hey, you know if we’re paying 50,000 dollars for a quality-adjusted life year for this medication, if that’s what it’s giving us, is that a good price or does the price need to be lowered so that the cost-effectiveness ratio is lower, that is more favorable?
Dr. Peter Neumann:
I think the other problem we didn’t get to, and I think is important for your audience, is even if we get to value-based prices there’s still this affordability issue for many people that will remain. In other words, the value-based price, as Dan said, could be quite high. It could be a million, 2 million dollars for a gene therapy. There’s a separate problem of out-of-pocket costs rising for many, many patients and that needs to be dealt with as well through insurance reforms. And there’s legislation that’s being discussed to do things like that.
Joe Elia:
Okay.
Dr. Joshua Cohen:
And that’s something that is towards the end of our book. It might even be in chapter 11, I can’t remember. So the way to fix accessibility is not to say, “Well, let’s make the price really low,” because then you run into an innovation problem. You want to have the right price, but then as a society we need to figure out how can everyone get access to the therapies at that right price? And that’s insurance reform.
Joe Elia:
Okay. I want to thank you Dr. Neumann, Dr. Cohen, and Dr. Ollendorf for your time with me today. And I want to mention, once again, that your book, The Right Price, is available (for a right price, I hope) from the Oxford University Press.
That was our 281st Clinical Conversation. We come to you from the NEJM Group and the writers and editors of NEJM Journal Watch. Kristin Kelley is our executive producer, and I’m Joe Elia, thank you for listening.
The post Podcast 281: Drug Costs — What’s “The Right Price” for prescription pharmaceuticals? first appeared on Clinical Conversations.

Multisystem inflammatory syndrome in children (or MIS-C) is a serious complication of Covid-19 infection, usually showing up about a month after infection.
CDC worked with several hospitals around the U.S. to discern whether vaccination in adolescents would lessen the likelihood of this outcome. A vaccine hadn’t yet been approved, as it now is, for kids between 5 and 11).
The bottom line is that vaccination with BNT162b2 (colloquially known as Pfizer-BioNTech) proved over 90% effective in preventing MIS-C.
Listen in as we discuss the work with CDC’s Laura Zambrano. The interview runs about 15 minutes.
The article in MMWR (free)
TRANSCRIPT
Joe Elia:
Multisystem Inflammatory Syndrome in Children or MIS-C is a troubling complication of COVID-19 infection. Does vaccination lower the risk?
You’re listening to Clinical Conversations from the NEJM Group. I’m Joe Elia, and I’m here with a principal co-author of a paper in MMWR published last week.
Dr. Laura Zambrano, the senior epidemiologist in the [Multisystem Inflammatory Syndrome] unit, which is a part of CDC’s COVID-19 Emergency Response Task Force, is here with us. Welcome, Dr. Zambrano.
Dr. Laura Zambrano:
Well, thank you. And thank you so much for having me.
Joe Elia:
You’ve been busy there at the CDC, I’ll bet. What prompted this research into MIS-C and how did you go about doing it?
Dr. Laura Zambrano:
MIS-C, as you mentioned, stands for Multisystem Inflammatory Syndrome in Children. And we understand it to be a post-acute hyperinflammatory syndrome that generally occurs between two and six weeks after a child tests positive for SARS-CoV-2. And it is a severe syndrome. It is characterized by fever, systemic inflammation and affects multiple organs throughout the body with a combination of severe cardiac, respiratory, gastrointestinal, mucocutaneous, hematologic, neurologic, or renal complications.
MIS-C was first described among patients in the United Kingdom and then in New York City in the spring of 2020. And since then, it has been reported worldwide. And higher MIS-C incidence really closely follows peaks of reported SARS-CoV-2 circulation, and it’s really a function of the number of infections reported among children. As of last week, we have received over 6,400 reports of children with MIS-C meeting our CDC case definition. And given the occurrence and recent surge of COVID we are anticipating, unfortunately, that a wave of MIS-C will soon follow, so we have our eyes on that.
So, all that to say we understand that severe outcomes related to COVID-19 can, and absolutely do occur in children, and MIS-C is one of them. And this is an outcome we are clearly hoping to avoid in children. We already have many studies that broadly show high vaccine efficacy and effectiveness against SARS-CoV-2 infection and severe COVID disease, but real-world effectiveness against MIS-C is a little bit trickier to assess. For one, MIS-C generally occurs after infection and can follow infections in children that are generally milder or even asymptomatic. And we felt we needed to quantify the degree of protection inferred by a vaccination against MIS-C in addition to some of these other analyses that have examined severe COID-related outcomes.
Joe Elia:
You describe the work as a test-negative case-control design, so could you oversimplify that for me?
Dr. Laura Zambrano:
Sure, of course. In any case-control study we’re looking to enroll patients who have a specific syndrome or outcome. And then we’re interested in exploring on a broad basis what exposures may have led to that outcome. And here, of course, the exposure is vaccination, really the protection. You know the exposure here is not being vaccinated, right, and development of MIS-C. So, what a test-negative case-control analysis involves, generally this is a standard study design used for other vaccine effectiveness studies: we take patients with a specific outcome, in this case MIS-C, and we match them to hospitalized controls.
In this case, these were hospitalized controls who fit into two categories: they either had a respiratory or COVID-like illness and actually tested negative for COVID-19 in the hospital generally by RT-PCR or possibly antigen, generally RT-PCR; or they could be syndrome-negative completely. And so, these could be children who are hospitalized for any other number of reasons, you know, they could be hospitalized, for example, as a trauma victim, but of course without any COVID-related symptoms. And so, we essentially pooled those together ultimately in our analysis, but one thing to note is that the vast majority, of course, of our syndrome-negative patients also tested negative for SARS-CoV-2 upon hospital admission.
Joe Elia:
Okay. And the way that you collected these cases, Dr. Zambrano — you had people across the country contributing these records. Can you talk a little bit about that?
Dr. Laura Zambrano:
Oh, yeah. So, this actually goes into this longstanding relationship that the CDC has had with Boston Children’s Hospital. And Boston Children’s Hospital has led a hospital network, and this is led by Dr. Adrienne Randolph who is really our principal investigator there, and the purpose of the original network was really to examine the effects of severe influenza in children. But early on in the pandemic we leveraged this network to create the Overcoming COVID-19 Network to better understand the clinical course of children hospitalized with severe COVID-19 and MIS-C.
We’ve used this platform to collect detailed clinical information on children hospitalized at over 70 hospitals across the United States. And one of these activities includes examining vaccine effectiveness against both hospitalization and critical COVID-19 illness in children and adolescents, and of course assessing vaccine effectiveness against MIS-C. In this particular study, we had 24 of these network hospitals that participated.
Joe Elia:
I see. Now, in terms of numbers of patients. You had, roughly speaking, and I’m going to talk in rough numbers here, you had roughly 100 patients with MIS-C.
Dr. Laura Zambrano:
One hundred and two, yeah.
Joe Elia:
These were all adolescents between the ages of 12 and 18.
Dr. Laura Zambrano:
Yes.
Joe Elia:
And then you had another, roughly, 200 hospitalized adolescents who were matched by various criteria. All right. So, what did you find?
Dr. Laura Zambrano:
Sure, I think really we had three overarching key findings.
Number one, the key finding here, I think, overall is that COVID-19 vaccination is highly effective in preventing MIS-C in adolescents. And how effective? We estimate 91 percent effective.
Number two, among the MIS-C patients we enrolled, 95 percent of them — 95 percent — were unvaccinated.
And number three (and while I still think it might be a little too early to tell for sure just because of the sample sizes that we were working with) overall, unvaccinated MIS-C patients appear to have more severe disease. This is really illustrated by the fact that nearly 40 percent of them required life support: they required some combination of invasive mechanical ventilation, vasoactive infusions to treat shock, and ECMO. But in contrast, none of the vaccinated patients included in the study required these treatments.
Those, I think, are the three overarching findings.
Joe Elia:
So, if I were to choose just one finding I would say ”Wow, only five percent of the MIS-C patients were fully vaccinated!”
Dr. Laura Zambrano:
Yes. Yes.
And you know one thing, I think, that is remarkable is we’ve seen that statistic highlighted time and time again regardless of almost whatever severe outcome we are looking at related to COVID-19. That, really, the overwhelming majority of patients exhibiting severe outcomes are unvaccinated.
Joe Elia:
So, the vaccination even among those children who came down with the syndrome, in that small group, their syndromes were less severe, that none of them required life support, or ECMO. And so, it seems, and as you calculated, the vaccine was roughly 90 – 91 percent effective in preventing MIS-C in those adolescents.
Dr. Laura Zambrano:
Yeah. And of course of note too, you know, one thing that we did notice is that ICU admissions also, I mean of course the sample size is small, but still, ICU admissions appear to be lower as well among the MIS-C patients. And so, we’ve seen consistently in our surveillance cohorts, for example, that the proportion (and this is looking at vaccination before or data from before vaccinations were available) that adolescents. requiring ICU admission has consistently ranged between 61 and 66 percent.
And again in this analysis we see among the unvaccinated patients about 63 percent of MIS-C patients required ICU admission, but among the five vaccinated patients only one — or really 20 percent — required ICU-level care. So, it’s still very early data. I don’t, you know, want to overinterpret it, but I do think it’s a promising sign.
Joe Elia:
And speaking of small samples, because you only had, I think, 81 or 84 or something like that cases, does this surveillance, does this research continue? Is it ongoing?
Dr. Laura Zambrano:
Sure. So, we have 102 cases, but absolutely the enrollment is continuing. And we really wanted to get this data out as soon as we felt like we had a sufficient sample size to get a reasonably precise estimate of vaccine effectiveness. But we absolutely are continuing to enroll patients. And you know specifically, I think, our next steps really are to look at the next-youngest age group, those 5 to 11 years old, who of course vaccination was just recommended for them starting back in November. And we didn’t have sufficient time, of course, to include them in this round of the analysis, but you know we are enrolling more of the 12- to 18-year-olds and we are enrolling the 5- to 11- year-olds right now.
Joe Elia:
And all the children who were vaccinated had received the Pfizer-BNT vaccine because that was the one that was available and had been approved by the FDA.
Dr. Laura Zambrano:
Yes, absolutely. And you know we set an exclusion criterion ahead of time that you know if a child had received another vaccine for some odd reason, even if they weren’t approved to do so, we would exclude them, but we actually did not see that. These children that were within this analysis all received the Pfizer vaccine.
Joe Elia:
Okay. Is there a question you wish I had asked you that I did not?
Dr. Laura Zambrano:
That’s a great question. You know one thing that I do want to emphasize, and of course this doesn’t have to go into the podcast this is just more me floating this by you, but this 5 to 11 age group is actually really important to us. And so, I would actually love to expand upon that a little bit more, mainly because the 5 to 11 year olds really appear to be the age group that’s disproportionately affected by MIS-C. And so, I’d love to just kind of talk about that age group a little bit more and the implications in this analysis for younger kids.
Joe Elia:
Sure, go ahead. And you’ve given a good introduction to the question, so I won’t ask it formally. Go right ahead.
Dr. Laura Zambrano:
The fact that the study here was focused on adolescents was really a function of timing. So, of course, the Pfizer-BioNTech vaccine was recommended for teens in mid-May, so we had this really nice window of time from July to December to study vaccine effectiveness in this group. But one thing that’s of real concern to us is that MIS-C is actually more common in younger kids. So, for example, the next age group eligible for vaccination, these 5- to 11-year-olds, are disproportionately more affected by MIS-C compared to other age groups.
So, as of last week, you know, when we posted this to our CDC website — to the CDC COVID Data Tracker, we have actually an MIS-C module there and I could direct your listeners to that webpage — but as of last week these 5- to 11-year-olds comprised 46 percent of all cases reported to the CDC. The Pfizer-BioNTech vaccine was only recommended for this age group back in November, you know, well that’s really the reason we weren’t really able to include them in this analysis, but we are currently investigating vaccine effectiveness in this group.
And one thing I want to emphasize is even though we don’t have a vaccine effectiveness estimate for the 5- to 11-year-olds yet, I don’t think there’s any reason to believe that vaccinations wouldn’t also protect these kids from developing MIS-C. So, we really want to use these findings from this study to encourage all parents to get their kids vaccinated to protect against the worst outcomes of this virus.
Joe Elia:
Okay. Well, I want to thank you for your time today, Dr. Zambrano.
Dr. Laura Zambrano:
Thank you so much for having me. And, Joe, one question that I would love to…or I do have a couple of statements I would love to make and you could sort of paste this or append this earlier in the podcast or where you see fit. But the one, I think, plea that I have for the public or for pediatric care providers in particular is truly, I mean, aside from being a public health professional and a scientist, I’m also the mom of a 4-year-old little boy and he is the light of my life. And so, this issue is extremely personal for me, and from that perspective I really view it as our responsibility to protect our kids and then really empower parents and pediatric providers with the information that will help them protect theirs.
Joe Elia:
Okay. I should emphasize that Dr. Zambrano’s views are her own and not necessarily those of the Centers for Disease Control and Prevention. That was our 280th Clinical Conversation. We come to you from the NEJM Group and the writers and editors of NEJM Journal Watch. Kristin Kelley is our executive producer, and I’m Joe Elia. Thank you for listening.
The post Podcast 280: MIS-C after Covid-19 in adolescents — can vaccination prevent it? first appeared on Clinical Conversations.

Kiarri Kershaw has written a simple letter in JACC — the Journal of the American College of Cardiology. The letter conveys a strong message: health inequities don’t act uniformly across one’s lifetime. Her examination of Black versus white mortality from all causes and from cardiovascular causes with the use of age-specific data shows places in the life of a population where health interventions could lower mortality risks. Using age-adjusted data to examine an entire population is too coarse an approach.
She and her colleagues found that older Black people (age 85+) show a survival advantage over whites, despite the fact that whites hold the advantage at every other age interval. There are several possible reasons for this, and Dr. Kershaw and my co-host Dr. Karol Watson offer a few.
This is probably the shortest Clinical Conversation ever, coming in at under 7 minutes. And it’s well worth your listening time.
Dr. Kershaw’s letter in JACC.
The post Podcast 279: Age-specific data do better than age-adjusted data in revealing health inequities first appeared on Clinical Conversations.

An internist at Massachusetts General Hospital, Dr. Joseph Betancourt also runs their program on equity and community health.
In this, the final entry in our four-interview exploration of race and clinical equity, Betancourt talks about the need for medical institutions to pay attention to what’s happening in their patients’ communities. To that end, MGH has a “bodega makeover” initiative to bring healthy food choices to local stores. (His grandfather’s bodega in Spanish Harlem likely served as an inspiration.)
Running time: 17 minutes
The post Podcast 278: Where equity and community health intersect — a conversation with Joseph Betancourt first appeared on Clinical Conversations.

Dr. Sheares talks about her experience with inequities. She believes that clinicians should aspire to be students of their patients as well as of the pathophysiology of the diseases their patients present with.
Listen in.
Running time: 20 minutes
The post Podcast 277: Race and clinical equity — know your patients — a conversation with Karen Dorsey Sheares first appeared on Clinical Conversations.

In this, our second conversation on race and clinical equity, Dr. Karol Watson of UCLA offers her observations on what she’s observed as a cardiologist trying to deal with treatment plans for patients who’ve lost their health insurance or have had to go to a plan that doesn’t cover what’s needed.
She reminds us that tagging people as “non-compliant” would often be better expressed as “unable to afford.”
Let me know what you think, please, at jelia@nejm.org
Running time: 10 minutes
The post Podcast 276: Pay attention to the structural barriers that contribute to clinical inequity — Karol Watson first appeared on Clinical Conversations.

We’ve conducted a set of four interviews with physicians on the topic of race and clinical equity.
The conversations center not so much on their published research, but on the roles that these physicians take in their organizations and, in addition, the stories they tell about their own experiences.
Our first is with Dr. Kimberly Manning, who’s a professor of medicine at Emory.
Let us know what you think. Write to me at jelia@nejm.org.
Running time: 20 minutes
The post Podcast 275: Race and Clinical Equity — a Conversation with Dr. Kimberly Manning first appeared on Clinical Conversations.

Apologies for the long silence. We have been off doing other things — one of which has been figuring out how to cover conferences. Last month, after much preparation, we covered the American Society of Hematology (ASH) annual conference; our second foray consists of brief coverage of the American Society of Clinical Oncology (ASCO) gastrointestinal cancer symposium.
We present a brief, pre-conference chat in this edition. It was conducted just before the ASCO conference began, to get a sense of our guides’ expectations. Those guides — David Ilson, Ghassan Abou=Alfa, and Axel Grothey — are interviewed here and will be interviewed again at the end of the conference. The are expert, respectively, in cancers of the esophagus; stomach, liver, and pancreas; and the colon and rectum.
In forthcoming interviews, I will share several of the interviews done with hematologists for ASH. I hope you will find them as fascinating as I have.
Running time: 19 minutes
The post Podcast 274: Preliminary Thoughts on the 2021 ASCO Gastrointestinal Cancer Conference first appeared on Clinical Conversations.

Eric Rubin is editor-in-chief of the New England Journal of Medicine.
I asked him how COVID-19 has affected that journal, which has been around since the War of 1812 and seen its share of pandemics.
Listen in — it’s the first in a planned series of interviews with the editors of the principal clinical journals.
Running time: 19 minutes
NEJM’s Covid-19 resources page
TRANSCRIPT
Joe Elia: Welcome to Clinical Conversations. I’m your host, Joe Elia.
Dr. Eric Rubin, a specialist in infectious diseases, took over the reins of the New England Journal of Medicine as its editor-in-chief about a year ago. He had just enough time to settle in before — you know — the biggest pandemic in a century arrived.
He’s kindly agreed to take part in what’s planned as a conversational survey of the editors of the principal medical journals about their takes on COVID-19. These chats won’t focus so much on the clinical science of the pandemic as much as its broader effects.
In addition to editing the Journal, Dr. Rubin is an associate physician at Brigham and Women’s Hospital and a professor in the Department of Immunology and Infectious Diseases at the Harvard T.H. Chan School of Public Health.
Welcome to Clinical Conversations, Dr. Rubin.
Eric Rubin:: Thanks, Joe.
Joe Elia: These have been strange times for medical journals, haven’t they?
Eric Rubin::They sure have. I don’t have much of a basis for comparison, but as far as I can tell, this is pretty unusual.
Joe Elia: Yeah. I mean how is the journal doing? You’re all working in isolation? You’re not up in the top of the Countway Library on Shattuck Street, these days, are you?
Eric Rubin:: Yeah. That’s right. We’re all shut down, although I must say it’s worked out pretty well to have people working from home. I suspect that, like a lot of businesses, we’re going to find that we don’t have all that many people in the office when we finally do get back.
Joe Elia: I remember from years ago the kind of bustling newsroom feeling at the journal offices, and you would have these conversations in the corridor, like oh, you know, “This thing just came in, you should take a look at it,” but you really can’t do that over Zoom so readily, can you?
Eric Rubin:: Yeah, I think that’s right. It’s not as if we haven’t lost something.
Joe Elia: Yeah.
Eric Rubin:: It’s so much easier for people to walk in and out of each other’s offices with questions or ideas or “Here’s just something cool,” so we miss that, and I’m hoping that we recapture that, but on the other hand, there’s a lot of just get the work done stuff that people can do very efficiently at home, much more efficiently.
Joe Elia: Yeah. Yeah. When I was there, people would say, well, you know, “How often does the journal come out?” And I would say “Every damned week.” It’s relentless.
Eric Rubin:: That’s right. It’s kind of relentless.
Joe Elia: Yes. So, have you been inundated with research reports?
Eric Rubin: We have. I will say it’s gotten a lot better, but at its peak, we were getting more than 200 manuscripts a day, 7 days a week, for a while, just on COVID-19, on top of really a pretty normal volume otherwise.
Joe Elia: Yeah, my gosh. So, electronics have helped you distribute that workload, I guess, but that’s a lot of reviewers to find.
Eric Rubin: It is. We have to filter, before we send out for review, pretty severely, and finding reviewers is also problematic because the reviewers that we want to use are also quite busy. They’re the people taking care of the patients with COVID or setting the policy.
So, people, I think the reviewers have been very generous, but it did mean that we took a rather severe cut when things came in, thinking, you know, “This just is not likely to make it, and the authors are better off going somewhere else, where they can get a real serious look.”
Joe Elia: Yeah. You know journals have often been called universities without walls, but now, a lot of information, especially biomedical information, is being swapped around on social media, but they are kind of universities without constraints. What’s your feeling about this — this kind of swapping of information that’s going on?
Eric Rubin: You know I have mixed feelings. On one hand, I like the fact that information is being democratized and anyone can see it and comment on it, and that’s certainly true of COVID-19, where we and many of our fellow journals are making everything available immediately for free access right away, immediately, so that everyone can read the same things that the experts are reading.
When I look at social media, though, there’s a real mix. There’s really learned commentary, and there’s real misinformation, and it can be hard, I think, for people to sort out what’s real from what’s not.
Joe Elia: Can journals then offer a kind of healthy skepticism and peer review? Is that what they can bring to the table?
Eric Rubin: I think for sure. There’s no question that we make a lot of changes in every manuscript that comes to us. We work together with the authors, but the final product generally looks a lot different from what was submitted and different from the preprint that’s been posted.
And some of those changes — a lot of them — are cosmetic. A lot of them are messaging questions, making them more understandable or more accessible or being very clear about what the investigators did, but a lot of them are substantial.
For example, it’s not unusual to change the conclusions of a manuscript and sometimes change them to the opposite of what the authors had said originally, and that’s a pretty big change, and it is.
So, I think we’re still playing a role in communications that is very important, and we do that, certainly, with the very big help of our peer reviewers.
Joe Elia: So, those changes, Eric, are made with the — of course — with the consent of the authors. I mean they’re not just made and published. I just want our listeners to understand that.
Eric Rubin: Absolutely. This is a collaboration with our authors.
Joe Elia: Yeah.
Eric Rubin: When we accept a paper, we’re a little bit different from many scientific journals. We generally decide, after peer review, immediately, we’re going to take this or we’re not. It’s very unusual for us to send it back and say, “You know, if you did some more experiments, we’d reconsider.” Generally, we write a letter that says “We’d like to publish this, but as long as we can work with you to make the changes that we think are necessary,” and those are — can be — very extensive.
Joe Elia: This pandemic is an event that’s affecting culture, in some ways in the same way that the AIDS epidemic did, and by which I mean that, you know, human interactions and politics as much as creating an urge to solve the problem biomedically, but would you agree that the pandemic has become unusually politicized?
Eric Rubin: It is. It’s very strange but absolutely. I think the parallel that you point to with HIV is a good one, and back when HIV was in its heyday and treatments were not so good…not that HIV’s gone away. I don’t mean to suggest that.
Joe Elia: Right.
Eric Rubin: But back when there weren’t many therapies and there was a very strong advocacy movement, it was a very frustrating time, and that led — and people may not recall this — but that led to a lot of sort of crackpot theories that got propagated very widely in the community and were ascribed to by a lot of people, and that really undermined, I think, their confidence in the system.
Now, in the case of HIV, what brought confidence back was having effective therapies. It really was a technical fix. It wasn’t a political fix. Now, we’re in an even more difficult situation, I think, because our most effective means for controlling the virus are simple. They’re social engineering, in a way. They’re wearing masks and social distancing and all the standard sort of stuff, and yet we’re not really able to implement them, in the US at least, as widely as we should because of this politicization of the questions.
Joe Elia: You know Rudolf Virchow, back two centuries ago, said that medicine is a social science, and these simple, you know, measures that you mentioned are part of the social science — probably — that needs to be done.
Eric Rubin: Well, you know, and I think that goes back, again, back to HIV. I think it’s a really good point. In HIV, all we had originally were control measures, and those control measures meant people had to change their behavior in ways that they didn’t want to change, and it was very difficult. The uptake of that was difficult, very parallel to today, and what made the difference was actually not a social intervention but a technological fix, and I think, once again, we’ve come to rely on technology that we’re incredibly reliant, right now, on the idea that a vaccine will be successful.
Joe Elia: You know, speaking of HIV, when I was at the journal, a long time ago, at the Shattuck Street offices, we had a telephone call from Michael Gottlieb in Los Angeles in 1981, and I happened to be the senior person in the office at the time, I think Bud Relman was off on one of his trips, and he [Gottlieb] said, “Gee, I’ve got four cases of something, how soon can you publish an article?” and I said, “Well, you know, 3 to 5 months is what we’ve got.” So, I said “What is it?”
And he said, “Well, you know, it’s this kind of infectious thing that’s predominantly among gay men,” and I said “Do you think it’s a public health problem?” And he said, “I do,” and I said “Go to MMWR [Morbidity and Mortality Weekly Report (from the Centers for Disease Control)] and submit it there.” And he did.
And the next day, Bud Relman was back — the editor of the journal in those days — and he called Gottlieb and said, “Yeah, go to MMWR and we’ll publish the whole thing later.” And we did in, I think, December, like something like 6 or 8 months later, we published his article.
So, I mean, Randy Shilts and his book “And the Band Played On” says, “Oh, you know, Gottlieb went to the journal and the journal pooh-poohed it.” But it’s not true, but it makes it…
Eric Rubin: And the journal had the first report, I have to say, in a medical journal of HIV back then. Technology is better now so that we can publish things much more rapidly, and we can get them online instead of in print.
Joe Elia: Yeah.
Eric Rubin: Like we had to do back then but that it still requires people, and that is still the resource that’s most difficult for us. We put a lot of hours into every article, and we’re still putting in the same hours. They’re just compressed into a weekend.
Joe Elia: Yeah. Early in the pandemic, the journal published a letter about asymptomatic, or yes, presymptomatic transmission, for which it was…it got some criticism. Turns out that it was correct, that the letter was correct, but that.. You’re on the firing line, a lot, aren’t you, as the editor? You can be accused of saying, oh, you know, the journal is trying to be first, and it’s not always…that’s…
Eric Rubin: Yeah. I think that’s right, and I think we should be criticized when we make mistakes, and we should act to try to rectify those. In that case, we happened to be right, and we were vindicated by subsequent studies, but you know that was a case of politics as much as anything. That was a message that people didn’t want to hear and they were very resistant to at the time.
You know it’s no surprise that the biggest subsequent issues, in general, in medical journals have been about hydroxychloroquine, which has a very faithful following, and when anything gets published, we have a lot of people who object if it…and we would have people objecting on either side if the article suggested that it worked or it didn’t, and we’re also in the position, put in the position…we get a lot of people writing, saying “Why didn’t you do this?” We didn’t actually do the study, so it’s a little hard for us to…but they’ll criticize our characterization of the study as positive or negative, and I think we’re doing the best we can, and it’s very fair to second guess us. That’s part of the interchange, but it can get a little personal.
Joe Elia: So, when you think about your role, Dr. Rubin, do you see yourself as a teacher, a referee, a ringmaster? When you think about your audience, who is it?
Eric Rubin: Well, that’s a really good question. We like to think of our audience as clinicians, as people who are taking care of patients. The truth is that we publish a range of things, some of which are aimed at practicing clinicians and are very practical. They can be the videos in clinical medicine which show you how to intubate a patient or how to do any given procedure or the CPCs, the various clinical series we have where discussants develop a differential diagnosis and come up with management plans for patients. The research articles, we try to characterize, at least in summary, in ways that anyone, that any clinician could understand the message. Now, the truth is, we do have, and we have more and more of what I guess I’d call experimental medicine, which is something that’s not yet ready for primetime.
It can be phase I studies. It can be first-in-man studies, occasionally, of new drugs or new techniques, and I still think that’s important because a clinician can see what’s coming next, what do we have to look forward to? This may or may not be a breakthrough, but it could be, and we’d like to get those out to our audience.
Admittedly, some of what we publish is very technical and is aimed at a subspecialist or occasionally really a researcher community, but we’re trying to serve everybody to some extent. Our goal is to make a difference in how people are treated, and I think we try to think of the audience that matters for making that sort of impact.
Joe Elia: If you considered yourself a ringmaster, how do you get the lions and tigers to behave?
Eric Rubin: Well, so, I guess that requires a little description of the process we go through to make decisions on manuscripts. Essentially, all the editors sit in a room, at least until we shut down the office. Everyone shows up. There are 30 people in a room, and every manuscript that’s gone through peer review and has some chance of being accepted gets presented. Actually, it’s very old-fashioned. The editor who’s handling it Xeroxes all the figures, hands them around, and then presents the papers if it’s a journal club, and then there’s a very interesting discussion where the experts in the room or the people of opinions in the room, or of educated opinions in the room, will bring up any aspect of it, was the design correct, are the statistics correct?
We have several PhD professors of statistics sitting in the room. Was it ethical? Was there equipoise? Could you do this study? Almost any aspect of it gets discussed, and at the end, we make a decision. It is kind of a strange position to be in to be the final decision-maker because so many people in that room know more than I do, but it comes to a balancing act of what do we think people really need to know, and what’s going to move the needle? And I think that gets discussed all the time. In fact, one of the key questions that comes up repeatedly is, “If we publish this, is it going to help or hurt patients? Are people going to take this incorrectly and potentially do harm, or is this really going to make a difference?” And if it’s really going to make a difference, we’ll definitely publish it. So, it’s a fascinating process. You know it’s the world’s best journal club.
Joe Elia: Well, I want to thank you, so much, Dr. Rubin, for speaking with me today.
Eric Rubin: Thanks, Joe.
Joe Elia: That was our 273rd episode. We come to you from the NEJM group. Our executive producer is Kristin Kelly, and I’m Joe Elia. Thanks for listening.
The post Podcast 273: The journals and the pandemic — NEJM first appeared on Clinical Conversations.

Dr. Paul Sax writes the closest thing that the NEJM Group has to humor. He’s serious, of course, since his blog “HIV and ID Observations” concerns all things infectious . But he sprinkles in the odd cartoon or links to … dog videos, fer cryin’ out loud.
He scours the ID literature (and we must include the social-media literature in that category) for interesting stuff to write about, seems to have a knack for summarizing whole conferences in 750 words, and often manages to give his readers a reason to smile in these fretful times.
We decided to catch up with him and ask him about his inspirations and for his advice. He doesn’t disappoint.
Running time: 10 minutes
Paul Sax’s latest “HIV and ID Observations” blog: “Carbapenems and Pseudomonas, Lyme and Syphilis Testing, a Bonus Point for Doxycycline, and Some Other ID Stuff We’ve Been Talking About on Rounds”
TRANSCRIPT:
Joe Elia: This is Clinical Conversations. I’m your host, Joe Elia. The current pandemic is leaving its mark all over the place, and one obvious area is in medical research. Clinicians are often hearing about new findings on their car radios on the way home or on social media. The credibility of that information is key.
Our guest, this time, is Dr. Paul Sax. He’s a contributing editor on NEJM Journal Watch Infectious Diseases, Clinical Director of the HIV Program, and Division of Infectious Diseases at Brigham and Women’s Hospital, and also a Professor of Medicine at Harvard Medical School.
Globally, he’s probably best known for his lively blog, “HIV and ID Observations,” which he posts almost every week on the NEJM Journal Watch site.
Welcome, Paul.
Dr. Paul Sax: Thanks, Joe, for inviting me.
Joe Elia: I’ve been reading your most recent blogs, which I’ll remind listeners are all available at Blogs.jwatch.org. One of the most recent is titled “Reaching Out to Infectious Disease Doctors in COVID-19 Hotspots: You must be truly exhausted.”
I get the sense that you’re talking more to working clinicians than policy makers or professors like yourself. Whom do you imagine is reading your observations?
Dr. Paul Sax: Well, I actually meant it for the entire infectious disease community. Kind of, if you think back a million years ago, to March 2020, we were starting to hear about this terrible thing that was coming our way. We all knew it was coming, but we didn’t know exactly when it was going to happen, and then it happened at different times in different parts of the country. So, while we were preparing here in Boston, and New York City was getting slammed, other parts of the United States were preparing, too, but they didn’t get hit the way we did in the Northeast.
So, you know, I have colleagues in Alabama and Atlanta and Florida and Texas and Arizona, and you know, things were pretty quiet there. They did have occasional cases, and what happened was that, unlike here, where we really got hit hard (and we fortunately, at least for now, knock wood, things are very quiet, for them,) they had a period of relative quiet and then, a large number of cases. So, they’ve had to sustain this intense involvement with COVID-19 response right from the beginning. Very tough.
Joe Elia: Yeah. You’ve been at this for just over 12 years, with the stated purpose, and I’ll quote, “Commenting on interesting HIV, infectious diseases, and other medical and not-so-medical news.”
Is that still your purpose and what has the reaction been over the 12 years?
Dr. Paul Sax: Well, it’s been really gratifying — and gratifying in a way that I never could have imagined. You know, I’ve always kind of imagined myself someday becoming a writer. I’m a frustrated comedy writer. Never quite made it to Hollywood, but I went to medical school and I went into this fascinating field, and I thought, you know, “Why not write about infectious diseases?” And I’ll tell you, my inspiration for the format really were some of the great blogging in the early 2000s, mid-2000s, where writing just exploded on the internet and I thought, “Wow, all this great writing available for free. Let me try my hand at it,” and I’ve got to thank Matt O’Rourke at NEJM Journal Watch for giving me the opportunity to do it.
Joe Elia: Well, in the not-so-medical department, you’ve been known to sprinkle in cartoons and lately, dog videos: “Olive and Mabel,” two Labradors. I’ll just say it’s British genius comedy, but what’s that got to do with infectious diseases, Paul?
Dr. Paul Sax: Well, you know, there’s this strategy that every infectious disease doctor does when you’re talking to patients — is you ask them about their exposures, and one of the ways we ask about exposures is you ask about pets, and of course, I wouldn’t probably be so fixated on the dog videos if I didn’t have a dog myself, which I truly love, but there is this sort of funny aspect of infectious diseases where you ask someone about their pet, and then they look at you like, are you out of your mind.
I remember one unfortunate person who had a motorcycle accident and we got to the point where we were asking about pets and he then acknowledged that, yes, he did have a new parakeet, and then our infectious disease fellow I was working with said, “What’s your parakeet’s name?” And he told us: Fruit Loop. And I thought, that’s a very funny name. Of course, it had nothing to do with his motorcycle accident, or why we were seeing him, but there are times when it is highly relevant, and you know, there have been many times when we’ve seen people, and for example, they’ve acquired an infection from their pet and sadly, sometimes it is their beloved dog.
Joe Elia: Now you’ve confessed, already in this interview, to wanting to be a comedy writer, perhaps, and maybe even a standup comic when you were younger. What deflected you from that noble cause and was there a book or an experience, an infection or something that deflected you?
Dr. Paul Sax: So, yeah, well, probably the thing that deflected me the most, and I’m going to say this because I’ve acknowledged this on the site, is my father. My father, who is a physician himself, comes from a long line of physicians, and his attitude, essentially, was, if you’re okay in science, then you become a doctor. And he could not understand why his son, who was okay in science (that’s me) would consider doing something like comedy writing. He basically said, “Just go to medical school and then after that, if you still want to be a comedy writer, see if you can make it work.”
So, thanks, Dad. I mean I really love my field. I find infectious diseases fascinating from A to Z and beyond, and it’s always challenging, never more so than today, and you know, I get to do somethings that are sort of vaguely related to comedy writing.
I do want to also say, that in college I had some truly outstandingly talented friends who became professional comedy writers and frankly, I don’t have their chops.
Joe Elia: You can drop some names if you’d like.
Dr. Paul Sax: Yes, well, he was very kind t let me interview him about his own experience with a life-threatening disease, but one of my friends was Andy Borowitz. Andy Borowitz, of course, is a prolific writer writer now for the New Yorker mostly, political satire, but he’s just an extraordinarily talented person. And then another brush with greatness is Conan O’Brien. Conan O’Brien was a college friend of mine, and his father actually is an infectious disease specialist, so it all comes round, eventually.
Joe Elia: Now you serve as a kind of medical-cultural reporter on rather mysterious viral infections — HIV and COVID-19. Information on these diseases — and especially now, COVID-19 — comes at us unremittingly. Is it a hopeless task to try to keep up, or is it essential to try to keep up, and how do you, as a reporter, keep up for other clinicians?
Dr. Paul Sax: Well, I would say it’s essential to keep up and the way that we keep up is different from the way it used to be. You know, it used to be, you would get your journal mailed to you every week or every month, depending on the frequency, and you would pore over the table of contents, and read the abstracts, and the interesting papers. You’d read the methods, et cetera, and then the results.
Now, rapid fire medical information comes at you really quickly. I want to say that there are some good things about Twitter. Twitter actually is a great place to see medical information very quickly, but it’s not adjudicated, so the next step, after seeing that information, is to try to look at it critically
And I think a really good example of that is the dexamethasone treatment for COVID-19. The first I head of that was, of course, on Twitter. This group in Britain was promoting their results and it was very exciting that they had a press release showing a randomized clinical trial had improved survival with dexamethasone, and I kind of made the point after seeing their summary, that it should become standard of care for people with COVID-9 and met the criteria that used in their trial. And as a result, practice-changing. Their study was practice-changing and now it has been given the blessing of the New England Journal of Medicine, and I think we can say without much risk of bias that that is very high praise indeed, to be accepted as a paper in that journal.
Joe Elia: Yes. I think you’re right. And finally, as a reporter yourself, is there a question you wished I’d asked that I didn’t?
Dr. Paul Sax: Well, you know, one thing I do on my blog, is I try to write in my own voice, and that is something that I feel like medical journals could use a bit more of, and if I were to give some feedback to some of the medical journals, it would be this, it would be that there is a role for the human beings voice in the august pages of these journals. It doesn’t all have to be edited to fit the house style. So, that’s one pitch for that.
Joe Elia: Okay. That’s good advice, I’ll pass it on.
Dr. Paul Sax: Please do. To my good friend, Dr. Eric Rubin.
Joe Elia: Thank you, Dr. Sax, for talking with us today.
Dr. Paul Sax: Thanks, very much, Joe.
Joe Elia: That was our 272nd episode. All of which are available free at podcast.jwatch.org. Our executive producer is Kristin Kelley, and we come to you from the NEJM Group. I’m Joe Elia. Thank you for listening.
The post Podcast 272: And now for something completely different… almost first appeared on Clinical Conversations.