Chapter 44 — Quiz

Twenty-two questions. A mix of recall, reasoning, and judgment. Several have no single correct answer and say so — those are graded on whether your reasoning is honest, not on whether it matches the key.

This is the last quiz in the book. Question 22 is not about peptides.

1. Why can a randomized controlled trial not answer the questions in this chapter?

a) Randomizing people to a drug policy would be unethical b) The unit of the question is a market, a norm, or an institution, and no counterfactual society can be constructed c) The endpoints are too subjective to measure d) The trials would be too expensive to fund

2. What does randomization purchase in a trial?

a) A larger sample size b) Statistical significance c) The counterfactual — knowledge of what would have happened to the same people without the drug d) Blinding of investigators

3. The ecological fallacy is:

a) Assuming a drug's environmental effects are negligible b) Inferring something about individuals from patterns in aggregates, or the reverse c) Confusing correlation with causation d) Generalizing from animal studies to humans

4. §44.2 rates the claim that widespread GLP-1 use will meaningfully change food industry products as 🔬. What is the stated reason?

a) The mechanism is implausible b) Food industry data is proprietary and cannot be studied c) The mechanism is clear and the direction predictable, but the magnitude has not been isolated from other forces acting on food demand d) Industry-funded analyses cannot be trusted

5. According to §44.2's Hype Check, what should you ask when a forecast about food industry impact carries a specific number?

a) Whether the source is peer-reviewed b) What data could have produced that number c) Whether the author has financial conflicts d) Whether the number has been replicated

6. Why does a chronic therapy that works create a harder budget problem than one that does not?

a) Effective therapies are always more expensive to manufacture b) It becomes a permanent recurring expenditure scaling with a very large affected population c) Patients demand higher doses over time d) Regulators require more post-marketing surveillance

7. Payer churn refers to:

a) The rate at which insurers change their formularies b) The movement of individuals between insurers, plans, and programs over time c) Turnover among staff who process prior authorizations d) Fluctuation in drug prices between quarters

8. The structural consequence of payer churn described in §44.3 is that:

a) Insurers cannot forecast their costs b) Patients pay more out of pocket c) The payer funding a decade of therapy is frequently not the payer capturing the avoided event d) Drug prices rise faster than inflation

9. Which is NOT one of the three honest limits of the cost-offset argument given in §44.3?

a) Offsets are usually partial rather than complete b) Offsets arrive later than the costs that produced them c) Offsets may accrue to a different organization entirely d) Offsets cannot be measured because event rates are unknown

10. Both stigma mechanisms in §44.4 operate through the same psychological variable. Which?

a) Perceived severity of the condition b) Attribution of controllability c) Social distance d) Anticipated contagion

11. The intensification mechanism holds that effective treatment can:

a) Cause weight regain that draws attention b) Convert a condition from misfortune into perceived negligence c) Make clinicians less sympathetic to patients d) Increase media coverage of body composition

12. According to §44.4, which access scenario would strengthen the intensification mechanism?

a) The drugs remain expensive and heavily rationed b) The drugs become cheap, covered, and easy to obtain c) The drugs are restricted to a narrow clinical indication d) Access varies unpredictably between regions

13. The chapter rates the claim "effective pharmacological treatment will reduce weight stigma" as:

a) ⚠️ Promising but preliminary b) ❌ Hype outpaces evidence c) NOT RATED, with 🔬 if forced onto the scale d) ✅ Strong clinical evidence

14. Why does the chapter argue that a non-informative rating is worse than no rating?

a) It wastes space that could carry a better claim b) It launders a coin flip as an assessment c) Readers will assume the rating is authoritative d) It violates the date-stamping rule

15. Which of these is listed in §44.5 as a cost of medicalization rather than a benefit?

a) Access to insurance coverage b) Direction of research funding c) Locating the problem in individual bodies rather than in environments d) Relief from moral framing

16. The "crowding out" mechanism in §44.5 describes:

a) Clinics becoming too busy to see new patients b) Political energy for structural change dissipating because a problem appears solved c) Generic manufacturers being pushed out by patent holders d) Effective drugs displacing less effective ones from formularies

17. In §44.6's four-phase access curve, what is described as well-attested and what is not?

a) The shape is well-attested; the timeline is not b) The timeline is well-attested; the shape is not c) Both are well-attested for peptides specifically d) Neither is well-attested; the curve is illustrative only

18. The chapter rates "these drugs will become substantially cheaper as competition arrives" as ⚠️ for the direction. What is the stated cautionary precedent?

a) Growth hormone b) Insulin c) Octreotide d) Teriparatide

19. §44.7 and §44.8 are constructed as lists of:

a) Predictions with probabilities attached b) Falsifiable conditions that would have to hold for each future to arrive c) Policy recommendations d) Ranked risks

20. The chapter issues one NOT RATED verdict on the grounds that the rating system does not apply at all. What kind of claim was it?

a) A claim with no published evidence b) A claim about a compound with no generic name c) A values question, turning on the word "primarily" d) A claim about a population too small to study

21. State the book's thesis as §44.9 gives it, in your own words, in no more than three sentences. (No key answer — graded on whether both halves are present and neither is softened.)

22. (The last question, and it is not about peptides.) Choose any confident claim you encountered this week from outside medicine entirely. Write it as a properly specified claim with a population and an endpoint, name the rung of evidence supporting it, and state one thing that would falsify it. (No key answer. If you can do this in under five minutes, the book worked.)

Answer key **1.** **b.** The barrier is structural, not ethical or financial. A trial isolates a variable at the level of an individual; these questions live at the level of markets, norms, and institutions, where no control society exists and nobody can be blinded to living in one. **2.** **c.** Randomization buys the counterfactual. Everything else a trial does is downstream of that. **3.** **b.** Note that it runs in both directions, which is the part most often forgotten. Option (c) describes a different and more famous error. **4.** **c.** The rating is about the state of the evidence, not about the plausibility of the mechanism. Rule 3 of the rating system: never upgrade with mechanism — and by the same logic, a clear mechanism does not license a magnitude. **5.** **b.** "What data could have produced this number?" Usually the answer is an assumption multiplied by another assumption. Peer review and conflict disclosure are useful but secondary here, because most of these numbers never enter a peer-reviewed venue at all. **6.** **b.** The problem is created by the drug working. A failed therapy is a small budget line; a one-course cure is a one-time cost; an effective indefinite therapy in a very large population is permanent recurring expenditure. **7.** **b.** **8.** **c.** Each payer, acting rationally in its own interest, has a reason to be the one that does not pay. That is a structural feature, not a failure of anyone's character — which is why the remedy has to be structural too. **9.** **d.** Event rates *are* measurable and are measured; the other three are the limits the chapter actually names. Note that (d) is the most confident-sounding of the four, which is part of why it is the wrong answer. **10.** **b.** Attribution of controllability is the strongest single predictor of how harshly a condition is stigmatized, and it is the hinge on which the whole section turns. **11.** **b.** Blame does not disappear; it relocates from having the condition to failing to address it. **12.** **b.** This is the uncomfortable implication: the two things most people want — wider access and less stigma — may be in tension through this particular channel. That is not an argument for narrower access. It is an argument that the cultural improvement would have to be won separately. **13.** **c.** Two well-supported mechanisms running through the same variable predict opposite outcomes, and the evidence cannot currently distinguish them. **14.** **b.** A rating implies an assessment. Issuing one where the evidence supports no directional lean dresses a coin flip in the vocabulary of evidence. **15.** **c.** (a), (b), and (d) are all in the benefits column, and all three are real. **16.** **b.** And it requires no one to intend it. A problem that appears to have a solution attracts less pressure for a different solution. **17.** **a.** Phase 3 has arrived in a few years for some drug classes and taken decades for others. Nothing about the curve tells you where the tick marks go. **18.** **b.** Insulin is the standing precedent throughout this chapter: a life-changing peptide, a very large population, and a price history in which "competition will eventually solve it" had a time constant measured in generations. Case Study 1 covers the arc. **19.** **b.** A prediction is mostly unfalsifiable until it is too late to matter. A set of conditions is a checklist you can run against reality as it arrives. **20.** **c.** Whether society should treat obesity *primarily* as a medical condition or *primarily* as a product of the food environment. The empirical components can be rated and are, elsewhere in the book; the word "primarily" is a judgment about allocation, and no trial resolves it. **21.** No key. A complete answer contains both halves — the revolution is real *and* the hype is real — and softens neither. Answers that resolve the tension in either direction have missed the point; the difficulty of holding both at once is the thesis. **22.** No key. If your claim has a population and an endpoint, if you named a rung honestly, and if your falsifier is something you could actually go and check, you have done the thing this book was written to teach. Note how long it took. It gets faster.