Category Archives: healthcare reform

When I was doing my Internal Medicine residency in 1981 to 1984, we held scientific medical journals in great esteem. The New England Journal of Medicine, for instance. It was published once weekly, about a hundred pages IIRC. At the end of the year, I sent my 52 copies off to a bindery to be glued into a hard-cover book format, to be cherished and consulted for years. That book was two or three inches thick. I did that for maybe five consecutive years; I’ve no idea where they are now. Probably in a landfill.

The told us on the first day of medical school, “Half of what we teach you will be obsolete in five years.” So continuing medical education is an imperative. One way to keep learning is to read medical journals.

You may be surprised to learn that I no longer read scientific medical journals very often. How do I keep my medical practices up to date? I work in the hospital side-by-side with surgeons and medical subspecialists (e.g., cardiologists, gastroenterologists). In general, I talk to them and watch what they do. If there is a ground-breaking new diagnostic tool or therapy, I’ll hear about it from them. They’re not in an ivory tower, isolated from patients. They’re in the trenches with me facing sick and hurting patients every day. I still read scientific medical journals, but take them with a nugget of salt.

I’m a science journal skeptic, questioning their reliability, objectivity, and relevance. But I’m not the only won. Check out the writings of Dr. Marcia Angell, former editor of New England Journal of Medicine, and Dr. John Ioannidis.

Seemay Chou had this to say about scientific journals:

I’m a scientist. Over the past five years, I’ve experimented with science outside traditional institutes. From this vantage point, one truth has become inescapable. The journal publishing system — the core of how science is currently shared, evaluated, and rewarded — is fundamentally broken. 

Vox Day has excerpted a TLDR from Chou’s article:

It might seem like publishing is a detail. Something that happens at the end of the process, after the real work of science is done. But in truth, publishing defines science.

The currency of value in science has become journal articles. It’s how scientists share and evaluate their work. Funding and career advancement depend on it. This has added to science growing less rigorous, innovative, and impactful over time. This is not a side effect, a conspiracy, or a sudden crisis. It’s an insidious structural feature.

For non-scientists, here’s how journal-based publishing works:

After years of research, scientists submit a narrative of their results to a journal, chosen based on field relevance and prestige. Journals are ranked by “impact factor,” and publishing in high-impact journals can significantly boost careers, visibility, and funding prospects.

Journal submission timing is often dictated by when results yield a “publishable unit” — a well-known term for what meets a journal’s threshold for significance and coherence. Linear, progressive narratives are favored, even if that means reordering the actual chronology or omitting results that don’t fit. This isn’t fraud; it’s selective storytelling aimed at readability and clarity.

Once submitted, an editor either rejects the paper or sends it to a few anonymous peer reviewers — two or three scientists tasked with judging novelty, technical soundness, and importance. Not all reviews are high quality, and not all concerns are addressed before editorial acceptance. Reviews are usually kept private. Scientific disagreements — essential to progress — rarely play out in public view.

If rejected, the paper is re-submitted elsewhere. This loop generally takes 6–12 months or more. Journal submissions and associated data can circulate in private for over a year without contributing to public discussion. When articles are finally accepted for release, journals require an article processing fee that’s often even more expensive if the article is open access. These fees are typically paid for by taxpayer-funded grants or universities.

Several structural features make the system hard to reform:

• Illusion of truth and finality: Publication is treated as a stamp of approval. Mistakes are rarely corrected. Retractions are stigmatized.
• Artificial scarcity: Journals want to be first to publish, fueling secrecy and fear of being “scooped.” Also, author credit is distributed through rigid ordering, incentivizing competition over collaboration. In sum, prestige is then prioritized.
• Insufficient review that doesn’t scale: Three editorially-selected reviewers (who may have conflicts-of-interest) constrain what can be evaluated, which is a growing problem as science becomes increasingly interdisciplinary and cutting edge. The review process is also too slow and manual to keep up with today’s volume of outputs.
• Narrow formats: Journals often seek splashy, linear stories with novel mechanistic insights. A lot of useful stuff doesn’t make it into public view, e.g. null findings, methods, raw data, untested ideas, true underlying rationale.
• Incomplete information: Key components of publications, such as data or code, often aren’t shared to allow full review, reuse, and replication. Journals don’t enforce this, even for publications from companies. Their role has become more akin to marketing.
• Limited feedback loops: Articles and reviews don’t adapt as new data emerges. Reuse and real-world validation aren’t part of the evaluation loop. A single, shaky published result can derail an entire field for decades, as was the case for the Alzheimer’s scandal.

Stack all this together, and the outcome is predictable: a system that delays and warps the scientific process. It was built about a century ago for a different era. As is often the case with legacy systems, each improvement only further entrenches a principally flawed framework.

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Steve Parker, M.D.

I’ll believe it when I see it.

Health insurance pre-authorization, for example, is when your eye specialist recommends removal of your cataracts so you can see again, but your insurance company wants some clerk or administrator to review everything and either agree or disagree with your physician. If disagree, no eye surgery for you. Unless you’re willing to pay entirely out-of-pocket. Mind you, the clerk does not have a medical degree and has never examined you or spoken to you. Isn’t this one of the reasons Luigi Mangione executed that healthcare executive?

From American Greatness:

Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. joined other federal health officials on Monday to promote an initiative to end the practice of healthcare insurance pre-authorization.

Kennedy was joined by Centers for Medicare & Medicaid Services Administrator Mehmet Oz as part of a roundtable discussion with insurers to discuss pledges made by the health insurance industry to streamline and reform the prior authorization process for Medicare Advantage, Medicaid Managed Care and Affordable Care Act Health Insurance Marketplace plans which account for most insured Americans.

The HHS Secretary commented on how when he joined the presidential transition team, he was told that the single most important thing he could do to improve the experience of patients across the nation was to “end the scourge of pre-authorization.”

Of course, the unsurers will argue that pre-authorization is necessary because those greedy doctors are recommending that surgery, MRI scan, specialty consultation, or physical therapy merely out of greed.

Steve Parker, M.D.