From a $350 suppository to an unproven drug that could cost Medicare billions, here are this year’s worst examples of greed and dysfunction in health care.

Boston, MA – When we think of innovation in health care, we expect it to be focused on medical treatments and technologies that save lives. But that’s not always the case. Sometimes innovation means finding creative ways to squeeze money from the system and the patients it serves. 

The Shkreli Awards, named for infamous “pharma bro” Martin Shkreli, are awarded each year to perpetrators of the ten most egregious examples of profiteering and dysfunction in health care. This is the fifth year that the Lown Institute, a health care think tank, has given out the awards, along with the help of a panel of judges made up of clinicians, health policy experts, journalists, and patient advocates.

“The pandemic has not slowed the brazen chase for profits by many in the healthcare industry,” said Dr. Vikas Saini, president of the Lown Institute. “By displaying all of this shocking material in one place, we hope to build demand for a better system.”

2021 Lown Institute Shkreli Award Winners

1. FDA fast-tracks unproven drug, defying its own advisory committee and putting millions of older Americans at risk
2. Family at heart of opioid crisis offered immunity despite harm to millions and deaths of hundreds of thousands
3. Catholic hospital system with mission to serve the “poor and vulnerable” creates billion dollar private equity fund while cutting services at safety nets
4. Drug manufacturer prices Covid-19 pill developed with federal funds at 40x its production cost
5. Hospital system files 19,000 lawsuits for unpaid medical bills, while receiving $700 million in Covid bailout funds
6. Hospital claims Medicaid doesn’t count as insurance, raids accident victims’ settlements instead
7. Woman leaves ER after waiting seven hours without being seen, hospital charges $700
8. Hospital steers patients to ER for Covid-19 testing, inflating bill as much as 30 times
9. Pharma companies use “charitable giving” to increase sales of their overpriced drugs
10. Suppository users experience discomfort of 5000% price increase

A complete list of winners with descriptions, sources, and judges’ comments is available at the Lown Institute website.

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Join leaders of the Lown Institute and panelists Will Flanary (aka Dr. Glaucomflecken) and Gregg Gonsalves, epidemiologist and AIDS activist, on Tuesday, January 11 at 1 p.m. ET for a countdown and discussion of this year’s winners.

About the Lown Institute

Founded in 1973 by Nobel Peace Prize winner Bernard Lown, MD, developer of the defibrillator and cardioverter, the Lown Institute believes that a radically better system of health is possible and generates bold ideas towards that goal. The Lown Hospitals Index, a signature project of the Institute, is the first ranking to assess the social responsibility of U.S. hospitals by applying measures never used before like racial inclusivity, avoidance of overuse, and pay equity.

Contact

Aaron Toleos, Lown Institute, (978) 821-4620, atoleos@lowninstitute.org

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BROOKLINE, Mass. — Every 80 seconds, a hospital in the U.S. delivers a low-value test or procedure to an older adult, putting hundreds of thousands at risk of harm, according to a new analysis from the Lown Institute, a health care think tank. The Institute today released a ranking of over 3,100 U.S. hospitals that examines success at avoiding the use of tests and procedures that offer little to no clinical benefit.

The Institute finds that more than 1 million tests and procedures performed in hospitals on Medicare patients from 2016-2018 met established criteria for overuse. Among the 12 low-value services measured, hysterectomy for benign disease, the placement of coronary stents for stable heart disease, and diagnostic tests like head imaging for fainting were particularly widespread, with more than 90 percent of hospitals overusing these tests or procedures.

“Overuse in American hospitals is a pervasive problem that needs to be addressed,” said Vikas Saini, MD, president of the Lown Institute. “Hospitals want to do better and these objective measures of performance can help them move forward.”

The nation’s top hospitals for avoiding overuse are not the most well-known institutions in the country, but regional health care providers. Notably, providers in the southern United States are absent from the list of top hospitals. The best performers for avoiding unnecessary tests and procedures are:

1. Scott County Hospital (Scott City, KS)
2. Beth Israel Deaconess Medical Center (Boston, MA)
3. West River Regional Medical Center (Hettinger, ND)
4. Highland Hospital (Rochester, NY)
5. Mayo Clinic Health System – Lake City (Lake City, MN)
6. Maine Medical Center (Portland, ME)
7. Sidney Regional Medical Center (Sidney, NE)
8. Mary Hitchcock Memorial Hospital (Lebanon, NH)
9. Healdsburg District Hospital (Healdsburg, CA)
10. Contra Costa Regional Medical Center (Martinez, CA)

New England & Pacific Northwest are best, south worst at avoiding overuse

Out of the 50 top performing hospitals, nine are in New England and 10 in the Pacific Northwest, making those regions stand out at the top of the list. The South was home to 41 of the 50 lowest-performing hospitals, with five of the bottom 10 located in Florida.

Elite hospitals hard to find at the top

The Cleveland Clinic (58th) was the only hospital from the current U.S. News honor roll to break into the Lown top 100 for avoiding overuse. Most others placed in the top third with Houston Methodist being an outlier at 2756th. Looking specifically at the overuse of coronary stents, Mount Sinai Hospital in New York ranked particularly poorly, having performed 1,230 procedures that were likely unnecessary in the three years examined.

Other notable findings:

• Nationwide, 64 percent of hysterectomies analyzed met established criteria for overuse. In North Dakota and Wyoming, the rate of hysterectomy overuse was 90 percent and 94 percent, respectively.
• Nearly one in four coronary stent procedures met established criteria for overuse nationwide. As many as 200,000 patients may have had stents placed unnecessarily over the years studied.
• Vertebroplasty, a procedure to inject cement into the spine, which has been found to be ineffective for osteoporosis-related fractures in numerous trials, is still overused by many hospitals. In Florida alone, more than 3,600 vertebroplasties were performed in the years studied.

Comprehensive ranking information including an explanation of methods is available at LownHospitalsIndex.org/overuse. Related research is published in the current issue of JAMA Network Open.

A launch of the Institute’s racial and economic Inclusivity rankings will occur May 25th, and a launch of the full 2021 Lown Institute Hospitals Index, including rankings across more than 50 metrics, will take place at the end of June. 

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ABOUT THE LOWN INSTITUTE: Founded in 1973 by Nobel Peace Prize winner Bernard Lown, MD, developer of the defibrillator and cardioverter, the Lown Institute believes that a radically better system of health is possible and generates bold ideas towards that goal. The Lown Hospitals Index, a signature project of the Institute, is the first ranking to assess the social responsibility of U.S. hospitals by applying measures never used before like racial inclusivity, avoidance of overuse, and pay equity.

CONTACT: Aaron Toleos, Lown Institute, (978) 821-4620, atoleos@lowninstitute.org

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“Being a part of the Lown Institute leadership has truly been one of the most rewarding times of my professional career,” said Brownlee. “I’m proud to have helped the organization become a force for change in the health care landscape, and I’m excited to see what comes next.”

The Lown Institute was founded in 1973 by renowned physician, humanitarian, and Nobel laureate Dr. Bernard Lown. Brownlee joined in 2013 and played a key role in expanding the organization’s work as a think tank addressing issues of health care value, accountability, and equity. Working closely with the president, Dr. Vikas Saini, Brownlee and the Institute put on the first major medical meeting on the problem of overtreatment, published a series of papers in The Lancet on overuse and underuse around the world, and created a roadmap for eliminating harmful polypharmacy in America. Brownlee also helped guide the conceptualization and development of the Lown Institute Hospitals Index, a groundbreaking project that assesses the social responsibility of hospitals, including measures of racial inclusivity, avoidance of overuse, and pay equity.

“Shannon has been a great partner and played a principal role in everything the Institute has achieved over the last eight years,” said Dr. Saini. “She is an exceptional writer and thinker who has rightly earned a reputation as one of the leading experts on the topic of medical overuse.”

Prior to joining the Lown Institute, Brownlee served as acting director of the health policy program at the New America Foundation. She is the author of the groundbreaking book, Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer, named the best economics book of 2007 by the New York Times. Brownlee is the recipient of numerous awards, including a Congressional Commendation, and was named one of “four writers who changed the world” by the World Congress of Science Journalists.

About the Lown Institute

Founded in 1973 by Nobel Peace Prize winner Bernard Lown, MD, developer of the defibrillator and cardioverter, the Lown Institute advances civic leadership, accountability, and value in health care. The Institute believes a radically better system of health is possible and generates bold ideas to that aim. The Lown Hospitals Index, a signature project, is the first hospital ranking focused on civic leadership and includes measures like inclusivity by race, avoidance of overuse, and pay equity.

Contact

Aaron Toleos, VP Communications, atoleos@lowninstitute.org, (617) 992-9349

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Now it appears that the independent doctors’ advocacy has helped to change that practice. In August 2020, the Society for Maternal-Fetal Medicine and American College of Gynecology released their recommendations for blood thinners in women undergoing c-section. The new guideline acknowledges the lack of evidence behind broad use of blood thinners for all c-section patients, and instead recommends treating just higher-risk c-section patients with these medications.

“The fact that 46 of us stood against this pharma-funded approach may have helped bring evidence to this guideline,” said Dr. Adam Urato, Chief of Maternal-Fetal Medicine at the MetroWest Medical Center in Framingham, Massachusetts, who led the effort by independent doctors to speak out.

Jeanne Lenzer, investigative journalist and one of the creators of the List of Independent Experts, sees this new guideline as an example of what independent doctors can do when they advocate for patients. “This could be the beginning of a movement in which doctors from the international List of Industry-Independent Health Experts can come together to challenge clinical practice guidelines – most of which are compromised by financial conflicts of interest,” said Lenzer.

Blood thinners for all?

In 2016, the National Partnership for Maternal Safety (NPMS) released a list of recommendations for reducing deaths from blood clots in pregnant and postpartum women in the journal Obstetrics & Gynecology, popularly known as the “Green Journal.” One of these recommendations was expanding the use of blood thinners to most women after a cesarean birth. Since nearly one third of births in the US are by c-section, that’s about 1.3 million women a year who would be put on blood thinners after giving birth. This broad expansion of blood thinners was concerning to doctors who noted that this practice “is not justified by the available data and has the very real potential of doing more harm than good.”

Urato was also very concerned that the NPMS guidelines may have been influenced by industry connections. NPMS has significant has financial ties to industry companies, including three that manufacture or sell blood thinners. However, the 2016 recommendations did not include any of these conflict of interest disclosures from the NPMS. Urato reached out to doctors from the List of Independent Experts, and soon had a coalition of nearly fifty professionals. They wrote a letter to Obstetrics and Gynecology, which was published in November 2019, describing their concern both about the conflicts of interest and lack of disclosure of these conflicts in the journal. The letter also got the attention of major media outlets like the Wall Street Journal.

A new evidence-based guideline

In August 2020, the Society for Maternal-Fetal Medicine and American College of Gynecology released new recommendations on preventive thrombolytic treatment for women undergoing c-section. The guideline authors write that all women having a c-section should be given compression cuffs to stimulate blood flow, and those with a history of blood clots or family history of blood clots should receive blood thinners. But for women at low risk of blood clots, there is not enough evidence to support that they receive blood thinners, they write, reversing the recommendation from the NPMS.

The SMFM/ACOG document outlines the potential benefits and harms of giving all women blood thinners. The authors note that even among women at high risk of blood clots after surgery, 640 would need to take blood thinners to prevent one episode of venous thromboembolism (a dangerous blood clot that starts in the leg). At the same time, blood thinners can lead to the c-section wound separating and bleeding after the operation; one in 200 women to take blood thinners after c-section may be harmed.

While using compression cuffs to get the blood flowing is an inexpensive and safe intervention, the decision to use drugs to get the blood flowing is not as straightforward, and depends on the patient’s level of risk from blood clots. The SMFM/ACOG recommends that patients with a personal history of deep venous thrombosis or pulmonary embolism or family history of blood clots receive blood thinners, although they acknowledge that there is still not a high quality of evidence to support this recommendation.

Challenging industry influence in guidelines

Obstetrics is far from the only medical field in which industry conflicts may influence clinical practice guidelines. Evaluations of guidelines for gastroenterology, dermatology, oncology, and more find that the majority of guideline authors receive industry payments, and many receive payments in excess of $10,000.

“This dynamic is harmful to patients and the public because it often results in recommendations that put the profits of the drug companies above the health of patients and the public. There is a desperate need for clinical guidelines that are not influenced by corporate cash,” said Urato.

When it comes to clinical guidelines for cholesterol and heart health, financial conflicts of interest not only affect panelists’ interpretation of data, they “can also blind panel members to the fact that neither they nor the peer reviewers have been granted access to the underlying clinical trial data,” said John Abramson MD, MSc, Lecturer in the Department of Health Care Policy at Harvard Medical School. “Without seeing the underlying trial data, guideline panel members are not able to ensure that the analyses they are integrating into their guidelines are accurate and complete.”

“The IOM/NAM recommends that no members of guideline panels have conflicts of interest (and certainly not a majority), and no chairs or vice chairs have conflicts of interest. But both of these recommendations are routinely violated, and this is highly likely to bias the guidelines in favor of the manufacturers,” said Abramson. “Independent physicians could bring attention to these violations.”

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Brookline, Mass. — The Lown Institute announces the election of Mary T. Bassett and Chris Kryder to its board of directors. Patricia Gabow, an existing board member, has been elected chair. These changes come as the nonpartisan think tank seeks to build upon the groundbreaking launch of the Lown Hospitals Index, the first ranking to evaluate hospitals on their success at civic leadership, including racial inclusivity and investment in community health.

“The times are calling for bold thinking to improve American health,” said Dr. Vikas Saini, president of the Lown Institute. “These board members bring deep experience in health equity, public health, and care delivery that will be invaluable to the Institute as we move forward with our work.”

Regarding the election of Patricia Gabow as board chair, Saini said, “Dr. Gabow has an outstanding record of leadership in health care that we are sure will help us grow our organization and expand our impact.”

Mary T. Bassett, MD, MPH has more than 30 years of experience in public health in a career dedicated to advancing health equity. She is the director of the François-Xavier Bagnoud (FXB) Center for Health and Human Rights at Harvard University and the FXB professor of the Practice of Health and Human Rights at the Harvard T.H. Chan School of Public Health. Prior to joining the FXB Center, Dr. Bassett served as New York City’s commissioner of health from 2014 to 2018. Dr. Bassett lived in Zimbabwe for nearly 20 years, where she served on the medical faculty of the University of Zimbabwe. She also worked as the program director for the African Health Initiative and the Child Well-being Program at the Doris Duke Charitable Foundation, and as deputy commissioner for Health Promotion and Disease Prevention at the New York City Department of Health and Mental Hygiene.

Chris Kryder, MD is a leader in healthcare data analytics and information technology. He is the founder of newly-formed New Era Medical Organizations (NEMO), and he is executive chair of Chicago-based Higi. From 2013 through 2020, Dr. Kryder was an executive partner in Boston-based Flare Capital Partners. Previously, Dr. Kryder served as executive chair of Valence Health (sold to Evolent), founder and CEO of the analytics vendor D2Hawkeye (sold to Verisk) and a co-founder of Generation Health (sold to CVS). Dr. Kryder was a primary care internist at the Massachusetts Institute of Technology for nearly two decades, and directed clinical operations for MIT’s corporate HMO. He received his BA (History) from the University of Buffalo, his MD from Georgetown, and his MBA from MIT. He was active on the faculty of Harvard Medical School, Division of Health, Science, and Technology for more than 25 years.

Patricia Gabow, MD, MACP is a national leader in delivery system innovation and the care of vulnerable populations. She retired in 2012 after 20 years as CEO of Denver Health and Hospital Authority (DHHA), an integrated health care system serving one of the poorest populations in the state of Colorado. Dr. Gabow is the author of more than 130 articles, 36 books and book chapters, including two recent books, The Lean Prescription: Powerful Medicine for Our Ailing Healthcare System and TIME’S NOW for Women Healthcare Leaders. She serves on the Robert Wood Johnson Foundation Board of Trustees. She is a member of the Association for Manufacturing Excellence Hall of Fame and the National Academy of Social Insurance. Earlier in Dr. Gabow’s career, she was an academic practitioner and medical researcher in nephrology focusing on polycystic kidney disease. 

ABOUT THE LOWN INSTITUTE

Founded in 1973 by Nobel Peace Prize winner Bernard Lown, MD, developer of the defibrillator and cardioverter, the Lown Institute advances civic leadership, accountability, and value in health care. The Institute believes a radically better system of health is possible and generates bold ideas to that aim. The Lown Hospitals Index, a signature project, is the first hospital ranking focused on civic leadership and includes measures like inclusivity by race, avoidance of overuse, and pay equity.

CONTACT

Aaron Toleos, VP Communications, atoleos@lowninstitute.org, (617) 992-9349

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Visit the official Shkreli 2020 Awards page >>

Brookline, Mass — Pharmaceutical companies and hospitals are at the forefront of the medical response to the pandemic, but they also dominate the 2020 Lown Institute Shkreli Awards for committing acts of greed and indifference in the face of great suffering. The number one spot, however, goes to the federal government’s PPE task force. Instead of coordinating with states to get lifesaving supplies distributed quickly, they handed the PPE over to private companies, leaving states to compete with each other in an overheated market while a national crisis raged.

The Shkreli Awards, named for the infamous “pharma bro” Martin Shkreli, are awarded each year to perpetrators of the ten most egregious examples of profiteering and dysfunction in health care. This is the fourth year the awards have been bestowed by the Lown Institute, a health care think tank that believes a radically better health system is possible. “Winners” are judged by a panel of clinicians, health policy experts, journalists, and patient advocates.

“The pandemic called for civic leadership in health care like never before, and these awardees weren’t listening,” said Dr. Vikas Saini, President of the Lown Institute. “They’re signals of deep dysfunction that must be addressed if Americans are to have the healthcare system they want and need.”

2020 Lown Institute Shkreli Award Winners:

1. Federal PPE task force gives lifesaving supplies to private companies to distribute, creating bidding wars and delay
2. Drug company Moderna uses $1 Billion in taxpayer funding to develop Covid-19 vaccine, sets highest price of any vaccine-maker
3. Hospitals with extra beds refuse to take uninsured patients from overrun neighboring hospitals
4. Nursing homes fail to protect most vulnerable Americans from Covid-19
5. Big pharma rejects global effort to cooperate on Covid-19, competes for profit instead
6. Hospital CEO pens op-ed justifying high vaccine prices, neglects to disclose $487,000 conflict of interest
7. Hospitals punish mask-wearing clinicians for “scaring the public”
8. Connecticut doctor uses town’s Covid-19 testing sites to bilk residents
9. Pandemic profiteers peddle fake and potentially harmful Covid-19 cures
10. Private-equity backed companies spend millions to protect surprise billing practices, while cutting physician pay and pocketing millions of pandemic relief dollars

A complete list of winners with descriptions, sources, and judges’ comments is available at www.LownInstitute.org/shkreli-2020.

About the Lown Institute

Founded in 1973 by Nobel Peace Prize winner Bernard Lown, MD, developer of the defibrillator and cardioverter, the Lown Institute advances civic leadership, accountability, and value in health care. The Institute believes a radically better system of health is possible and advances bold ideas to achieve this. Their signature project is the Lown Hospitals Index. It’s the first hospital ranking focused on civic leadership and includes measures like inclusivity by race, avoidance of overuse, and pay equity.

Contact

Aaron Toleos, Lown Institute, (978) 821-4620, atoleos@lowninstitute.org

The post PRESS RELEASE: Top-ten pandemic profiteers, health system malfunctions take spotlight in 2020 Shkreli Awards appeared first on Lown Institute.

Older adults are more susceptible to medication overload than younger adults, because they take more medications on average and have reduced ability to process medications compared to younger adults, said Fulmer. Not only are older adults at greater risk of side effects than younger adults, but the consequences of these side effects may be greater as well. 

“I’m a practicing nurse and I see how taking multiple medications can cloud a patient’s cognition,” said Fulmer. “If they fall, they’re more likely to suffer a hip fracture than a younger person.”

Medication is one of the “the 4Ms” the Hartford Foundation recognizes as being critical to creating Age-Friendly Health Systems, along with Mentation, Mobility, and what Matters to the patient. Making sure patients’ medications are working for them is essential, because medication overload can affect not only physical health, but mental health, financial security, and the ability to enjoy everyday activities. 

“Getting medications right is essential because when your medication is wrong, your mentation can be off, your mobility can be compromised, and what matters to you will not be front and center,” said Fulmer. 

Read Dr. Fulmer’s full interview on the IHI blog!

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Many of these startups promise improved health through increased access to testing (such as blood testing or genetic sequencing), monitoring (constant tracking of steps and heart rate, for example), and personalized care (such as health and nutrition plans based on genetics). However, the evidence that these functions improve health is slim, the authors write. Genomic sequencing has not been shown to improve population health or change health behaviors; wearable fitness trackers don’t actually help people lose weight; and personalized health plans rarely give people information about diet and exercise they don’t already know. 

The promise of health from these startups is based on the assumption that focusing on individual behavior is the answer. However, they ignore that individual health habits themselves are “affected by a set of socioeconomic factors, which together with environmental conditions affect how long we live, our mental well-being, and a host of other health outcomes.” 

Brownlee, Saini, and Miller conclude, “If Silicon Valley really wants to disrupt the health care sector in a way that has the most impact on people’s health, it needs to bake an understanding of community conditions into whatever ideas they put forward.” 

Read the full op-ed here, and the Lown Institute report on California’s spending on community conditions!

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Proton beam machines have become increasingly popular investments for health systems, despite the lack of evidence to support the use of proton beam therapy (PBT) for all but a few types of cancer. Comprehensive reviews of the evidence by the independent nonprofit Institute for Clinical and Economic Review in 2014 and the American Society of Radiation Oncology in 2012 found evidence of net benefit from PBT only for ocular tumors, brain and spinal tumors, and pediatric cancers, compared to standard radiation treatment.

Even more recent research hasn’t helped the case for PBT. A 2016 report from the Canadian Agency for Drugs and Technology found that “overall, none of the clinical evidence was suggestive of a substantial incremental benefit of PBT over photon radiotherapies.” In 2016, the first randomized controlled trial for PBT for lung cancer found it no more effective than conventional radiation therapy and no less toxic. And a 2018 systematic review of quality of life and patient-reported outcomes after PBT found increased benefit only for certain brain, head and neck, lung, and pediatric cancers.

As Emanuel points out, there aren’t enough patients with ocular, brain, or pediatric cancers to warrant so many proton beam machines in the region. So why do hospitals keep building them? Because hospitals would rather refer patients in-house than lose cancer patients to other health centers, explained Brownlee. Unfortunately, as we’ve seen with complications at some pediatric surgery centers, having more centers that conduct fewer procedures each actually increases the chance of complications.

“The reality is, if you are one of the rare adult cancers that can be treated more effectively with this machine, it’s a lot better to send you to a place that does it all the time and has a lot of experience with it,” Brownlee said.

Increasing investments in unproven therapies like PBT is not just a financial risk for the hospital–it increases health care costs for everyone. If insurers pay for PBT (which they are being increasingly pressured to do), insurance premiums will go up. If they don’t pay for PBT, the hospital may cut into other areas to cover their costs. And perhaps most importantly, we have to take into account the enormous opportunity cost of investing in PBT rather than more impactful community health initiatives. 

“There’s real harm in spending money on something that’s not better and is more expensive,” Brownlee said, “and that harm is that hospital is not investing in something else that could improve its community or improve the health of more patients.”

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But don’t despair–in the latest edition of NPR‘s Life Kit series, Lown Institute Senior Vice President Shannon Brownlee, patient advocate Liz Salmi, and Johns Hopkins surgeon Marty Makary offer some tips on how patients can maintain control over their health care in stressful situations. The segment was hosted by Georgetown University family medicine physician Mara Gordon and general internist and President of the University of Oklahoma John Schumann.

Listen to the radio piece on NPR here!

Salmi used her story of receiving a diagnosis of brain cancer to illustrate some of the challenges in dealing with the health care system. “The words of what you have are delivered in really technical speak. They don’t say, you have brain cancer. They say… you have a grade two astrocytoma,” said Salmi. Other challenges include not knowing which doctor to contact about which issue, getting access to doctors’ notes, and learning all of her options before making treatment decisions.

“Any doctor who doesn’t want you to get a second opinion is a doctor you shouldn’t be seeing” — Shannon Brownlee

The panelists emphasized the importance of having a primary care doctor be the center of your care team. “We have primary care doctors who want to be in the loop of everything that happens with that patient. You want someone who’s fighting for you like that,” said Makary.

However, when making a major treatment decision, getting another doctor’s opinion is key. “Any time you are told, you need a seriously invasive procedure, you need a second opinion,” said Brownlee. “Any doctor who doesn’t want you to get a second opinion is a doctor you shouldn’t be seeing.”

Taking your time to weigh these options once you know them is extremely important; you should not feel rushed into surgery if it’s not an emergency. Brownlee suggests questions to ask your doctor before embarking on a major procedure: What happens if I don’t get treated? What are the chances this treatment will work for me? How will this affect my quality of life? And in general, a doctor’s outright dismissal of your concerns without an explanation should be a red flag. 

For more tips, listen to the full piece on NPR.

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