We, too, can be health economists

Yesterday Dr Jason Guertin presented on the overlap between pharmacoepidemiology and pharmacoeconomics, challenges to translating research into decision making and the potential transition between epidemiology and health economics.

The speaker introduced the incremental cost-effectiveness ratio (ICER), and went on to describe the confounding challenges to determining it.  This ratio is the increase/decrease in cost per unit change in effectiveness (e.g. quality of life or years gained unit) for a new drug/technology, compared to its predecessor. The ICER is the key outcome in pharmacoeconomics and cost-effectiveness research for health technologies in general. It is analogous to the usual health outcomes we study in epidemiology. Similar to epidemiology, confounding is a problem in cost-effectiveness research based on observational studies. However, the ICER is actually composed of two things rather then just one health outcome – the cost component and the effectiveness component. Confounding takes on new life because of these two outcomes and the positive or negative correlation between them.

In epidemiology, our effect estimates can swing above and below the null when confounders are excluded or included.  In cost-effectiveness research, the cost per quality of life years gained can swing above and below the acceptable threshold to approve new drugs/technologies for reimbursement. In an extreme example, Dr Guertin found a difference of up to $80,000 per quality-adjusted life year gained between unadjusted and adjusted models.  Evidently such a price tag has practical implications for decision-making – in this case whether to approve a new technology to treat aortic aneurysm.

Beyond the actual study, translating findings into policy faces further complications. The public reaction has a bigger influence on the technologies and drugs approved then even the best quality cost-effectiveness studies.  For example, a very expensive drug to treat rare genetic disorders in infants may be approved because of the value society places on young lives.  At the same time, treatments for hair loss are not approved for reimbursement despite their extreme cost-effectiveness.  In epidemiology, we face similar challenges. For example, maternity leave allowances of 6 weeks may lead to better breastfeeding outcomes.  Say the research on this issue was perfect.  Would the policy be implemented everywhere? No.

In sum, Dr Guertin effectively translated his health economics research into a language epidemiologists could understand.  The overlap in confounding and study design-related challenges demonstrated that the skills also overlap.  So, pharmacoeconomics may be a new field to pursue for you!





Am I passionate enough about my PhD?

We are often told passion is one of the most important aspects of a PhD.  That if you don’t like your topic or field of study, you are doomed from the start.   It is idyllic, actually: being so passionate about your topic that you will never procrastinate, you will put in 110% every day, and, most of all, have a lifelong devotion.

Realistically, choosing a topic is one of the biggest challenges for graduate students even if you are floating in a cloud of passion. Regardless of whether the topic is from a blank slate or a continuation from previous work, for many students, passion goes something like this:

  1. An initial idea driven by passion and excitement (and practicality)
  2. Excitement builds and you feel confident
  3. Excitement dwindles and you question everything
  4. Repeat 2 and 3 until you end up in a static state of one or the other

The scary part is ending up permanently at step 3. What does this mean? Should you stick to your plan of becoming a tenured expert in fruit fly migration? Regardless of your PhD stage, divorcing yourself from a career path you had perfectly planned and a topic that used to be your passion is not impossible. Practically, one can always apply to non-traditional jobs post-PhD, and build contacts to transition into preferable topic areas and career paths.

At the same time, pursuing alternate plans is more difficult then it seems. Think about the achievements that are rewarded in our department, where reward = verbal praise, postings on the news websites, congrats from professors, wow factors at thesis/protocol defense.  These ‘wow factor’ achievements include awards at conferences, speaking invitations, novel methods, publications in NEJM, CIHR funding..Someone who has all these things is a ‘very good’, ‘very bright’ student. We all like praise, so adhering to the above model is highly tempting despite dwindling interest in the topic and career path that’s receiving the praise.

Unfortunately, similar external validation is not available for alternate plans, making two things necessary to move on from your set-in-stone path. Admitting the mismatch between previous thinking and the current state of mind, and learning to rely on internal validation are mind games that must be overcome.  So what if no one notices that you just published a very creative idea in a very mediocre journal? You should be proud, when you think of yourself explaining this idea to someone who will notice, at a time when it actually matters for you. Learning to define your own achievements is a pre-requisite to defining your own path beyond the PhD, and ultimately finding a career that is truly driven by passion.

Further reading for those interested:

Dr. Levine could no longer focus on astronomy with developing political events 

Dr Borniger started a PhD in a different field despite success in anthropology

Top 10-alternative careers for STEM PhDs & the importance of understanding your options

I hate my PhD