You may or may not know (I don’t know why you would, honestly), but I speak Swedish. I mention this because there’s this famous and really culturally emblematic Swedish word which is this: lagom. It means “the exact right amount.” In Swedish culture, the exact right amount deserves its own word. For example, “Did you have enough watermelon?” “Why, yes, I had half a slice. It was lagom.”
Lagom has no direct translation in US English because, in the United States, we don’t need a word for “the exact right amount.” Why? Because the exact right amount already has a word: the most. More. More is always better.
I think this shows up in health care in this country, and it definitely showed up in my conversation with Dr. Bishal Gyawali in this health care podcast. There’s this cultural bias in this country that more is better. The point I’m making is that there’s a sort of fundamental belief that aggressive therapy—the most aggressive therapy—is the best therapy and conservative therapy, or following the treatment pathway that works for the majority of patients, is kind of like a surrender.
It’s not about being pro or anti anything. It’s about being data driven. It’s about finding the “lagom” amount of care that the data suggest is the best amount of care and not immediately assuming that if something isn’t done that it’s been a subpar outing.
In this health care podcast, I’m talking with Bishal Gyawali, MD, PhD. Dr. Gyawali is a practicing oncologist; assistant professor at Queen’s University in Kingston, Canada; and he has studied and worked in Nepal, Japan, and the US, and now in Canada. He’s a thought leader in studying the data impartially and finding ways to help patients and oncologists systematically make the best decisions toward high-value oncology care that is not financially toxic.
You can listen to Dr. Gyawali sum this up in his own words or read his paper on the topic, but here’s his top-line suggestions:
Follow NCCN and ASCO guidelines.
Payers: Negotiate drug prices based on clinical benefit—and this means you, too, Medicare.
Hospitals: more price transparency up front but also for the doctors. Financial toxicity is a thing. It’s been shown that patients who are suffering from financial toxicity die earlier. So, this is definitely data that a doctor needs to know as much as some kind of clinical decision-making factor.
Hospitals: Have a financial advisory desk.
Correct the misincentives at the physician/patient level (ie, all that’s going on with “buy and bill”).
You can read Dr. Gyawali's published paper in JAMA and connect with him on Twitter at @oncology_bg.
Bishal Gyawali, MD, PhD, is a medical oncologist with work experience in various low- and high-income countries. He graduated medical school in Nepal with seven gold medals and received his PhD from Nagoya University, Japan, as a MEXT scholar. He then practiced as a medical oncologist at Civil Service Hospital, Kathmandu, Nepal. He currently works as a medical oncologist and scientist in the Division of Cancer Care and Epidemiology at the Queen’s University Cancer Research Institute in Kingston, Ontario, Canada, where he is also an assistant professor of public health sciences. He was a research fellow at PORTAL (Program On Regulation, Therapeutics And Law) from 2018-2019.
He also serves as a medical consultant for the not-for-profit Anticancer Fund, Belgium, and as editorial board member for the Journal of Global Oncology and ecancer. His clinical and research interests include cancer policy, global oncology, evidence-based oncology, financial toxicities of cancer treatment, clinical trial methods, and supportive care. Dr. Gyawali is an advocate of the “cancer groundshot,” a term he coined to imply that research investment should be made on known high-value interventions in cancer care that are affordable and easy to implement globally. Dr. Gyawali is active in the oncology and clinical research communities on Twitter.
03:18 Oncology decisions on the individual level and oncology policy decision making.
05:10 Reverting to the mean.
06:29 “We’re assuming … more care is good care, which is not necessarily true.”
06:49 “What we need to focus on is above-average level of health outcomes.”
07:55 “Sometimes we forget the goal, and we get so entangled in the path itself that we forget the destination.”
11:19 Cutting out low-value care during the pandemic.
12:09 Reevaluating cancer screens and looking at the evidence for appropriate use cases.
13:24 Distinguishing the term “survival” from “mortality.”
16:34 “If a person dies, it does not matter what the person died of.”
17:26 “A lot of the things that we do routinely in medical practice need to be reevaluated.”
18:53 The FDA approval of oncology agents and things that make a difference.
20:37 “What exactly are we gaining from these drugs?”
20:53 EP282 with Aaron Mitchell, MD, MPH.
23:15 Dr. Gyawali’s advice to policy decision makers.
23:42 Policy decision-making interventions that are possible.
24:50 “The problem with these guidelines … is that a lot of these people who are on these guidelines, they have huge conflicts of interest to the industry.”
26:58 How to pay less for low-value care.
27:42 A better path forward to pay for value.
31:02 Ways to help on the individual level.
32:07 “At the end of the day, the ultimate use of an intervention happens in the clinic.”
34:24 “We should never be pro or anti anything; we should just be pro-data.”