Vinay Prasad, MD, MPH
Vinay Prasad, M.D., M.P.H., is a hematologist-oncologist and assistant professor in the OHSU School of Medicine. He is nationally known for his research on health policy, evidence-based medicine, bias, and medical reversal. Clinically, Dr. Prasad specializes in the care of lymphoma patients. He holds appointments in the Department of Public Health and Preventive Medicine and the Center for Health Care Ethics, where he is a Senior Scholar. We sat down with Dr. Prasad to talk about the formation of his career, his current projects, and where he sees his work going.
What’s your background?
I’m a Midwesterner from the Chicago area, and I didn’t stray far from home when I started college — I went to Michigan State University and then the University of Chicago. At MSU, I studied philosophy, writing, and science from several terrific professors, who pushed us really hard to think about our assumptions, and question them.
That was a good foundation for my experience at the University of Chicago as a medical student, which was a really special place for people who were thinking critically about medicine. I had a chance to work with physicians who cared about medical ethics, as well as those who cared about medical evidence, and all of them were superb. Finally, I completed my training at Northwestern University — where I had still more excellent role models in evidence-based medicine, and my hematology-oncology training at the National Institutes of Health, which, for me, was the ideal place to train.
When we think of medicine, we think of science, of proof. But it wasn’t until the 70s, 80s, and 90s, that we really developed a field of medicine that prioritized evidence. Before, this time though evidence was used here and there, the bulk of what you learned as a doctor was based on some very senior person telling you that’s how things were done — “This is how you recognize disease and this is what you do about it.” It comes as a shock to people outside of medicine that all medicine wasn’t always based on evidence, and, to some degree, still is not.
What knowledge do you want to see medical students graduate with?
First, you want doctors to be conscious of bedside manner. In 2016, it is of paramount importance to be good at that, and I think our training is getting much better at teaching the right skills.
Second, medical students definitely should graduate knowing how to think critically, evaluate a paper, and how to interpret statistics. The more you practice medicine, it becomes less about memorization and more about critical thinking. I also think that critical thinking is not synonymous with forced research projects. I think maybe we should move away from thinking medical students should graduate with a few research abstracts on their CV, which often rely on very unreliable methods—because that is what can get done in the time allotted. Instead, I think we have to teach the appraisal of medical evidence much more formally—much greater emphasis on study design, reliability, and how to make inferences from data. We have to teach students that medicine in the 21st century is a field where you will always be learning.
The prerequisites for medical school are tangential to medical school — calculus, physics, and organic chemistry — not to say there are no doctors that use those, but most don’t. People say those prerequisites teach you critical thinking, that they teach you memorization. But there are better ways to teach memorization and critical thinking. Philosophy is arguably something that trains you to think very critically; logic trains you to think critically; statistics too. I would consider those things. But again I would experiment, rather than mandate.
It was really in the last year of medical school and the first year of my residency that I got interested in research. I always thought I’d simply go into private practice —then, on a whim almost, I submitted a paper I had worked on — a paper that some senior person deemed “not scholarship”— to a journal. It ended up being published in the Hastings Center report. It’s fair to say that the kind of research I do — not many make a career of it. So it took me a while to realize that you can have any kind of career you want. You just keep doing it and eventually someone calls it a career.
What research are you conducting now?
Well, we have a lot of projects underway. A lot of what we’re doing is at the intersection of policy and funding and we’re doing a lot of work on is how we should pay for medical practices. If you’re in oncology, the cost of drugs is something that you cannot avoid. And we’re doing a little bit of work on in conflict of interest, prioritizing randomized-controlled trials, and some about research funding.
My goal is to try to do work that’s impactful. I aspire to do work that is read and hopefully leads people to change. For that reason I abandon a lot of projects at the outset — projects that I don’t think will be impactful, or will be published in one of the fifty thousand journals that frankly, no one reads. So, I think a lot about what I want the work to be.
Studying FDA drug approval is a big thing. Because, while there are a few drugs that are wonderful, a lot of the drugs the FDA approves are very marginal. So we’re doing a lot of work to ask should those drugs be approved, how should they be studied if they are approved, and under what circumstances should they be pulled off the market.
We have a new paper in JAMA Oncology where we start with what I think is an uncontroversial premise — that the purpose of the FDA is to approve drugs that improve survival or quality of life for people in America. That’s their purpose.
A simple fact is that the majority of drugs approved in cancer over the last 10 years are marginal. The median improvement in survival is about two months. And the clinical trials they’re conducted in are unrepresentative — they study younger and healthier patients. And, finally, when you look at how unrepresentative marginal drugs do in the real world, the answer is that they don’t do well at all — we have some evidence that shows some may not work at all.
Our conclusion is that it’s time to treat overall survival — what has always been a gold standard endpoint — in unrepresentative clinical trials as a surrogate endpoint for survival in the real world. So maybe we should actually have post-marketing commitments and grant only provision approval. Survival is, probably often, merely another surrogate. Like response rate and progression-free survival, as long as it’s conducted in unrepresented populations.
How are you finding OHSU and Portland?
I like being here at OHSU. I’ve been really impressed with my colleagues — across campus there are so many things going on. People at OHSU are working on clever projects. I think the funding for research here allows scientists to treat research as research.
I find a lot of people very like-minded on the topics I research. Pretty much, everyone I’ve met in internal medicine — and people across OHSU really. There are several senior people here who are tremendously supportive.
As for the city of Portland, I love it. I like to ride my bicycle and go on hikes. And to restaurants and the bookstore. But really? I love to binge watch television and movies. Now, Game of Thrones. And, for all time, my favorite show was the Wire.