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Why Doctors Hate Science
theodp writes "A 2004 study found some 10 million women lacking a cervix were still getting Pap tests. Only problem is, a Pap test screens for cervical cancer — no cervix, no cancer. With this tale, Newsweek's Sharon Begley makes her case for comparative-effectiveness research (CER), which is receiving $1 billion under the stimulus bill for studies to determine which treatments, including drugs, are more medically sound and cost-effective than others for a given ailment. Physicians, Begley says, must stop treatments that are rooted more in local medical culture than in medical science, embrace practices that have been shown scientifically to be superior to others, and ignore critics who paint CER as government control of doctors' decision-making."
Substantially less useful; but not entirely useless. Breast Cancer in males is uncommon; but not unheard of.
I'm 53 and my physician makes a regular practice of PSA tests for men my age, actually I started having them @ 50. Also just had my first colonoscopy recently and good thing as I had one tumor removed that was pre-cancer.
This is rule of thumb, and Dr. Merenstein should have known this.
Actually the previous poster is right. Population based studies suggest that more harm than good is done by screening for prostate cancer.
The evidence goes like this. Once you have an elevated PSA, you see the urologist who orders a biopsy. Biopsies and treatments for prostate cancer carry risks like bleeding and infection, urinary incontinence and impotence. Now most prostate cancers will not kill you or cause problems in your lifetime. So investigations and treatments for prostate cancer cause more harm to people than the cancer does. This makes sense in a population, but not to the guy who got a bad cancer.
The current guidelines do not suggest PSA's in all men over fifty, but rather that you discuss the risks and benefits of screening, plus potential harm of further workup of a positive screen vs. the harm of developing prostate cancer. In practice, there is no patient who can actually understand enough of this to truly make an informed decision. Many docs haven't heard of the 'new' evidence and continue screening. The ones who do know of that evidence often ignore it because it's hard to explain, and patients will love you for finding an early cancer, even if it would never have affected them.
As far as your colon cancer screening comment, what you describe is standard of care.
The other thing to consider is that medicine in the US is HUGELY biased by the litiginousness of US culture. US emergency medicine guidelines, for example, are extremely aggressive and notorious for over investigating. The priority is protecting practitioners from litigation rather than appropriately treating the patient. A lot of those investigations are not recommended in socialized health care systems because they are not cost effective, nor do the benefits outweigh the disadvantages.
1. Private insurance will not pay for a woman's well visit if they don't have a Pap smear. They don't care that the woman doesn't have a cervix. If you don't do it, you don't get paid, and it's just easier to do it no matter how nonsensical it is than it is to get on the phone with someone who is not medically trained and argue that, yes, you did do a well woman exam even though you didn't do a Pap smear.
2. There is a case to be made for anal Pap smears, because HSV also causes anorectal cancer in people who participate in anal sex. Unfortunately, because it's not standard of care, private insurance won't pay for that either. (We don't even need to talk about Medicare or Medicaid because they don't pay for preventative visits.)
There are a few reasons for what you're talking about. I am a primary care provider myself, a nurse practitioner, and the BIGGEST reason we give out the drugs the reps bring us is because when we give out the drugs we get as samples there is no cost to the patient. You would probably be shocked at how many people can't afford a $4 wal-mart prescription. If this means I give aciphex instead of prilosec I'm going to jump on that pretty quickly.
That said, there was a recent ethics thing where drug reps can't give us pharma schwag (I'll miss getting my viagra clock every year...) anymore, nor can they take us out to dinner at expensive restaurants. *sniffle*
In conclusion, even if you don't have a cervix it makes sense to get a pap of that area, because if you don't have one it probably means that you had all those bits removed for some reason, and the dysplasia or cancer may be present in the areas immediately adjacent to what was removed. Sometimes it doesn't make sense, but sometimes it does.
I call shenanigans. When *I* listen to my patients' hearts, I'm listening for new or changed murmurs, irregularity in the rate, bounding of pulses -- and you're taught to do things systematically, and for a reason. Insurance companies give us about 15 minutes per patient if we want to be able to keep our head over water, so if you think anyone wastes time with useless mumbo-jumbo, you're way off-base. Anyway, you don't diagnose a "heart attack" with your stethoscope.
>I'm sure if you did a study of "average" gastroparetics you could say "due to evidence-based medicine, everyone should take medicine X", and this might be fine for 60% of the patients while forcing 40% into ineffective treatment. Medicine needs to address the individual needs of patients.
Exactly! To bring up a further point about patients as individuals, the Government just announced that testing PSAs for men over 75 is pointless. Which is ridiculous; their entire line of reasoning is based on the odds of the patient dying of something else before they die of prostate cancer. And now let me bring up my father, who had his PSA tested around the age of 75. Unlike most of America, he eats right, exercises nearly every day, has never smoked and has drank alcohol sparingly. He is the perfect candidate to get further PSA testing, because he is less likely than your average American to die of "something else" in the case he has an indolent prostate cancer. Which, in fact, he did - an intermediate-high grade (Gleason 7) prostate cancer that was still local and eminently treatable. But following the Government's advice today for "Best Practices", he would have stopped testing, and this malignancy would have metastasized and in all likelihood killed him.
Light a fire for a man and he'll be warm for a day. Light a man on fire and he'll be warm for the rest of his life.
The truth is doctors aren't geniuses. They sat next to you in high school. Some of them copied your answers on the math test. They are average everyday people that have been trained (hopefully well) to do a specific job.
MDs have a median IQ significantly higher than all other measured professions. That is to say, the average, everyday median MD IQ at ~125 is already halfway to official "genius" level.
The notion that "Doctors Hate Science" is absurd.
Da Blog
Go talk to someone in the military about that whole free government provided healthcare...you get what you pay for...
I agree that the VA is underfunded relative to its size and patient population but, given its funding limitations, it's actually the best performing health system in the US when measured objectively in terms of patient outcomes.
Da Blog
To throw in a real world data point to back your claim, my healthy, active and vibrant 82 year old grandfather went in to have an operation to deal with prostate cancer, his doctor suggested that as he was in such good shape if he got rid of the cancer he could live on for quite a while longer.
He died suddenly in the hospital from internal bleeding caused by the surgery a few hours later. Now the cancer might have gotten him eventually, but how long, five years? ten? He was 82 and healthy and happy so it was kinda pointless operating really.
He thought so too, but let himself be talked into it by his doctor.
Worst thing was he was completely lucid, happy and rational minutes before he died, it was very sudden and unexpected.
In France, we actually have a dual system.
Public hospitals and private clinics.
Everyone is covered and can go to the hospital. 'The rich' as you qualify them, will go to the clinic and thus pay more, getting things such as a personal room instead of a shared one in the public hospital.
Doctors can get the money from working at the clinic because they also have to work part-time at the hospital.
No 'bribing' involved. Just some common sense and both parties are satisfied.
Yes, we all know that (arguably) most docs don't keep up with the literature. Or they choose a treatment and stick with that because it worked the best at one point and they like it because they trust it. Problem is, that research is ongoing and new things are found all the time. In fact, on one of my clicking adventures on-line, I found out that Lithium Carbonate was being used to treat refractory depression (as an adjunct), OCD, cluster headaches and even ALS (the one that Stephen Hawkins has) to name a few. All that in *low* doses. Yet, most docs still consider this a horrid drug refusing to realise that in low doses Lithium Carbonate does _not_ require close monitoring.
So, this sort of study could be very beneficial.
HOWEVER, it's things like this that HMO's really *really* like. They'll probably use it to force doctors into treatments that are cheaper alternatives regardless of that particular patient. Because, as with many things, certain disorders, etc, have different drugs to treat them. Different drugs for different sets of symptoms, different severity of symptoms, etc, etc, etc. So, patients will likely get cheated out of drugs that would be more effective for them simply because there HMO won't pay for the one that is best for them and the one that is best for them isn't in there price range. Especially, for the more complicated disorders.
And what happens when next week happens and this changes. How often is this list going to be updated? How often are the HMO's going to be updating from the research?
Quite frankly, while I fully believe that this thing is undertaken with the best of intentions, it is ripe for abuse. In the end, it is my opinion, that it'll likely lead to more harm than good.
HMOs and federally mandated employer-based healthcare was proposed and signed into law by President Nixon. In fact, there is an infamous tape of Nixon and his adviser discussing the plan as proposed by Edgar Kaiser of Kaiser Permanente where they blatantly talked about how the emphasis would be on profit (for the HMO) and "providing less care."
What we have today wasn't the result of some master-plan hatched in a secret lair in the lower recesses of an evil University by bleeding heart liberals or whatever you've been told. No, our entire employer based healthcare system is the result of special interest pork legislation written by the industry and pushed upon the public by a Republican administration. It's the DMCA of 1971.
With regard to your child's heartburn, you need to start asserting yourself as a patient and parent. Take an active role in your child's health and specifically ASK your doctor for generic prescriptions. I'm going to go out on a limb and guess that your doctor prescribed Nexium or some other namebrand Proton Pump Inhibitor. The generic, Omeprazole, is available Over-The-Counter, costs a fraction of the price, and works virtually identically. Call your doctor and ask him or her if this is appropriate for your daughter. No doctor I've ever met would mind a call such as this. In fact, I think most would welcome it. Fifteen seconds of his or her time for one potentially satisfied, engaged patient is what you call a clinical no-brainer.
-Grym
A few facts first:
1) Pap smears still make sense in women after a hysterectomy. It is then called a vaginal vault smear. It is meaningful at the very least in women who had abnormal smears prior to hysterectomy, because abnormal cells can have spread to the surrounding vaginal wall
2) Some surgeons leave a stump of the cervix behind when they perform a subtotal hysterectomy. Not common practice any more, but used to be very common in many countries and can have some advantages for the stability of the pelvic floor. Not all women who had a hysterectomy know whether they still have a cervix stump or not.
3) When the hysterectomy was performed for malignancy, eg cancer of the uterus, the vaginal vault smear can be useful to detect early recurrence
Hence. some women may not need pap smears after a total hysterectomy - but in many women this is still a meaningful and cost effective procedure - which is why even public health systems are still happy to pay for them.
The article does not seem to take this properly into account - because most scientists have only a very limited insight into medical problems. I should know - I did a science degree first before becoming a MD.
There already is a lot of competition driving health care costs down.
Yes but where is the competition to bring the standard of care up? There is some. Some employers will offer multiple health plans, but it's more like Verizon vs. AT&T than figuring out where to eat lunch. The McCain plan was an obvious, painless, and timely way to improve health care for Americans. All Obama has delivered, to this day, is promises.
The appallingly bad knowledge, especially about new drugs, family doctors have is downright frightening.
All the points being made here are very pertinent, but one factor I have been dealing with (handling my elderly mother's medical care as she is no longer capable of keeping track of things) is that doctors today just have too heavy of a workload. They are juggling so many patients that they cannot possibly devote the time they really need to every individual case. The tendency is to just diagnose and order tests/prescribe drugs based on the most common knee-jerk diagnosis that comes to mind. The House M.D. depiction of a group of doctors having the time to sit around and debate diagnoses with intricate knowledge of every exotic possibility and with ready knowledge of all the latest medical research simply does not happen in most hospitals.
Example: for over two decades, my mother has dealt with achalasia, a swallowing disorder. It is not a common problem, but certainly not some exotic rare disease that no one has heard of. She does have a very capable gastroenterologist, and the problem is currently under control, but it does rear its ugly head now and then. When my mother has been hospitalized and treated for other problems, the achalsia is still a factor as it affects her diet and eating schedule. You would be amazed at the number of attending physicians to whom I have had to explain and define what achalsia is and how it should be handled. Different doctors will all come and go in the course of her stay, none of whom seem to talk to each other at all, or have any inclination to inquire of her gastro doc about the problem, and all of them skeptical at best and disdainful at most of this "layman" son of hers trying to tell them how to do their job. When the achalasia begins to manifest (usually because they ignore or are clueless about the standard recommendations for diet), they keep automatically attributing it to nausea or reflux or some other unrelated condition and try to treat her for that. I can't sit in her room 24/7 waiting to intercept any random new doctor that happens to breeze in at odd times for one of their brief drive-by visits to "educate" them about achalasia (and somehow this information either never gets into her chart, or gets overlooked by these doctors in their overworked haste), so she ends up getting unnecessary treatment for problems she doesn't have. And this is not in some hellhole of a hospital -- this is in the highest-rated, most modern facility in our metro area.
Much as I would like to see some form of universal health care soon, this phenomenon will just be exacerbated by suddenly adding 30 or 40 million new formerly uninsured patients into the system. Doctors already do not have the time to give each patient the time and care they need. Unless they train or import a whole lot of new medical talent quickly, it's just going to jam up the system even more, and there will be an even greater tendency for doctors to make diagnoses and treatment decisions "on the fly" as they breeze through on their way to their next patient.
"Every great cause begins as a movement, becomes a business, and eventually degenerates into a racket." -- Eric Hoffer
I've experienced both systems first-hand -- I'm an American living in Britain. Government-provided health care is FAR superior to what I received in the USA. Easier to get, cheaper, and of equivalent quality. No comparison.
I piss off bigots.