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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."
While I am all for people being able to make their own calls and decisions, this sort of research could very well help to streamline more basic medical procedures and help bring to light both new medicines and treatments that might not be able to afford the same advertising as the crap that gets shoved in front of consumers every ten minutes on tv, radio and internet.
The musings of just another geek and his junk.
the assumption here is that wasteful procedures are due to the profit motives of physicians.
anyone who knows anything about health-care will tell you that the primary cause of most non-cost-effective procedures is fear of legal consequences.
want cheaper healthcare? reform the legal system and get the hmo's out of the game.
------ The best brain training is now totally free : )
... as the title of this entry suggest. Not all doctors are created equal, and lets get this straight - all human beings, no matter how educated are very fallible and human.
I had one young doctor think I should have my moles checked out that "looked cancerous" and another doctor whom I'm also freinds with that tells me "that doctor is full of shit". I also had my GP (general practitioner) suggest I had a part of my foot cut off after a series of infections after many an ingrown nail, needless to say I rejected his suggestion and did the work on the foot myself and still have everything all intact and normal as ever.
Just because someone suggests something who is in a position of recognized credentialed authority, does not mean it is a license to take their judgments and advice without scrutiny and a grain of salt.
Knowing how to do this and when is the hard part, but this is something that only people who've lived long enough and have the wherewithal to gain by experience - mankind is extremely fallible. Therefore critical skepticism must be employed when decisions can have significant consequences.
It's easy for experts to suggest something to someone else when they don't have to bear the risk and consequences of going through with it.
Next up:
Which conflates the argument that doctors sometimes do those (and other) stupid things. They don't have to....
And another gem:
What the fuck is wrong with this woman? Did somebody do a prostate exam on her? Yep, there is a problem - doctors don't necessarily do what sometimes iffy research describes as best practices. And there is the big issue of why medical practice varies so much from region to region. And doctors very definitely tend to do things that pay them money (i.e., procedures) when perhaps they are better off not doing so.
But this 'article' is just an idiotic rant. There are fairly large and well funded groups that find it in their best interest not to go along with this idea, but to paint everybody with the same brush and to dismiss detractors of CER is just immature. Unfortunately, for the vast majority of patients, we really don't know what is the best combination of treatment or not treatment. Most of the studies have been done for fairly short periods of time and on rather homogeneous populations. It's hard to know how those studies apply to the real world patient in your office.
Let's take the little issue of pap smears after hysterectomies. If you had a hysterectomy for actual cervical cancer, then you ARE supposed to keep getting pap smears (at some unknown frequency). That's because cancerous tissue doesn't necessarily stop growing the moment it wanders off it's initial tissue base. That's why it's a cancer.
Way to go Newsweek. Take an important, complicated issue and create a brain dead sound bite.
Roll up your sleeve and bend over.
Faster! Faster! Faster would be better!
I practice evidence based medicine as much as possible. The trouble is that patients have a very hard time understanding it, let alone appreciating it.
I don't give antibiotics for colds, but those patients often go see other doctors to get their antibiotics. When they get their inappropriate prescription, ironically I come across as a bad doctor for not prescribing it in the first place.
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it. Parents hate that.
I have a cranky baby at home. My friends asked me why I don't use Oval. I told them that there is evidence that it doesn't work. They stared at me like I had three heads. After all, they tried it and it worked for them!
People come in with back pain. My job is to rule out the dangerous causes, and once that's done give them some analgesia and tell them to weight a few weeks for it to improve. Any serious pathology will reveal itself over time if there are no red flags during the initial history and physical. Patients hate that. They want the xray. So they go to their chiropractor who orders a bunch of xrays (placebo 'tests' are very therapeutic to patients actually). "Well, your xray looks fine!"
EBM is hard on the practitioners. The old school of medicine is to say, "This is what you have and this is what you need to do to fix it."
Now we say, "It's likely that you have this, although I can't say for certain. Here are the pros and cons of the treatments. Now what would you like to do?"
Very dissatisfying to a lot of patients.
Everyone wants all the scans and tests even when it doesn't make sense, because they all know the guy who was told that his problem wasn't serious and it turned out to be cancer etc.
The previous party line was that all diabetics should be on aspirin to decrease their chances of having a heart attack. A recent study came out showing very little evidence for primary prevention of heart attacks with aspirin. What to do now? How to integrate every little bit of often conflicting evidence into clinical practice? It's very hard to stay up to date, let alone sift the wheat from the chaffe.
EBM is the gold standard of how we should practice medicine. Yet it is immensely frustrating to put into actual practice.
Data is not the plural of anecdote.
While I understand the need to have a catchy title, it's grossly mis-representative of the problem. Doctors don't hate science - doctors hate the misapplication of science and the failure to apply common sense. Hence, pap smears for patients without a cervix.
The relevant question is not how common the test is.
The relevant question is, would it have made any difference?
The problem is when you introduce two separate institutions that were never really meant to interoperate. There is a perception by the general public that doctors should be like House, or Scrubs, or a dozen other TV shows out there where everyone is a genius, and the cure can be found in a 1 hour episode with just a few tests, a quick flip through a book, and some snarky commentary. It's the same with criminal investigations -- the so-called "CSI effect". Juries now want "DNA evidence" to prove someone was at a scene (or not), something that's both impractical and often unnecessary, and cases have been lost simply because the evidence was "too boring".
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. When the justice system (and the general public's expectations) meet the medical establishment, it's not pretty. Evidence is poorly understood, and when people don't understand something intellectually they fall back on their gut feelings, their emotions. As horrible as that sounds (and sometimes is), what can we really expect from Joe Average? A carefully-weighed judgment, with full knowledge and understanding of the evidence? Please.
Here's a hard truth to swallow: All that stuff about a "jury of your peers", and being judged by people who are well versed in the law (but not necessarily the material issue at hand), doesn't work in modern society. Our method of voting and elections are horribly outdated as well, and there are dozens of systems which (at least statistically) would provide "better" results. But we as individuals want to believe we understand things well enough. We want to believe that we are righteous, and just, and overall good people. And we very well may be, but that means exactly dick in the larger equation. Just as we have specialists in medicine, technology, and elsewhere, we need a justice system, a political system, and other institutions to mirror society in it's specializations -- judges who have IT training, or medicine, etc. Politicians who make decisions about, say, telecommunications who have worked in the industry. Because society has become too complicated for us to have just judges, or just lawyers, or outdated concepts like a "jury of our peers"... Who's only qualifications were that they registered to vote in your county.
If you want change, start by choosing the right people for the job, because contrary to popular belief in this country, not just anyone can do these things.
#fuckbeta #iamslashdot #dicemustdie
When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it.
Have you considered that, although it's no better than placebo, it might be better than nothing? Saying it's no better than placebo doesn't actually mean that they won't see a difference if you don't prescribe anything. It's why they use placebos in trials.
I have considered it. I also consider the fact that every medicine I prescribe carries risks, even if those risks are low. If I don't know whether the risk outweigh the benefits, I don't prescribe, particularly for 'nuisance' illnesses.
I know many physicians who prescribe placebo treatments and tests. I have trouble doing this even though patients find it very satisfying. What I sometimes do instead is tell people what the evidence is and let them decide. I struggle with the ethics of prescribing a placebo.
Couple that with having to do unnecessary tests many times just to CYA to fight off bloodsucking lawyers and malpractice cases....well, that explains a lot of it away.
Light travels faster than sound. This is why some people appear bright until you hear them speak.........
Almost. The perception is that doctors should be like doctors were before a medical license became a ticket to becoming a millionaire. There was really a time when a successful doctor might have the nicest house on the block, but not also a nice house in St. Lucia and a nice house in Aspen and a nice apartment on the Gulf Coast. So now doctors fear that if we have universal health care in the US, they might have to go back to being part of the community in which they serve. The people who are going into medicine these days are doing so because there were no more spots left at Northwestern's B-school. Forget for a moment that our insurance-driven system has turned medical practitioners from independent actors into assembly-line employees. The 30%-plus profit margins that are built into every medical cost are going less and less to pay for the doctor's new Mercedes (or for their mistresses' breast implants) and more and more to the pockets of companies that have nothing to do with medicine. I actually lived in a time when almost all hospitals were non-profit, but that was back in a rosier time in our history when we had a booming economy and a 90% top income tax bracket (go figure).
We have learned that "free market" medicine does not guarantee a healthier populace, nor does it even guarantee the best health care system.
Of course doctors hate science. They're afraid that it might show that the product they provide is overpriced and ineffective. Then we'll end up with socialized medicine, which as we are constantly told is only one step away from gulags and a Supreme Soviet.
You are welcome on my lawn.
If practicing medicine consisted of a video game or a board test, then yes, doctors could suspend their own judgement in favor of strict evidence-based medicine. Unfortunately, this is the Real World, and doctors frequently have to approach EBM with a healthy dose of skepticism.
The problem with EBM is threefold: the evidence record is necessarily incomplete; many real-world patients have very little in common to patients that make it through selection criteria into randomized clinical trials (RCTs); it is very easy to skew studies in minute ways through endpoints, study design, and a thousand other ways that are difficult for busy practicing physicians to catch.
Want some examples? A recent multicenter study (in worldwide sites) of blood pressure medications funded by the maker of Lotrel found that their combination ACE inhibitor/calcium channel antagonist (CCA) had slightly better morbidity/mortality outcomes over a given period of time than patients who were placed on a combination of the ACE inhibitor and a thiazide diuretic, with similar reductions in blood pressure. The data is fantastic, and the outcomes are probably real. But when you check closely into the outcomes criteria, one of the "bad" endpoints is "hospitalization for unstable angina" (new or worsening chest pain). One of the indications that CCAs have that diuretics do not is the treatment of angina. CCAs, through the mechanisms of its action, can prevent anginal episodes or make them better. A thiazide diuretic will not treat angina directly. Out of the room of ~20 doctors this study was being presented to, apparently I was the only one who thought of this. And since many of the patients involved in the study had prior cardiac history with ostensible angina, it made perfect sense why CCAs would perform better for these patients. But this study is not being billed as that - the study is being presented as evidence of the possible superiority of using one drug over another in the general population with high blood pressure.
And then there's the Nexium/Prilosec fiasco. Nexium was developed by the makers of Prilosec when patent protection for Prilosec began running out. (You can buy generic Prilosec (omeprazole) over the counter.) Nexium (ESomeprazole [emphasis mine]) is filtered Prilosec - the biologically active enantiomer of Prilosec's racemic mixture. Nexium is on average six times more expensive, mg for mg, than generic omeprazole. The only study I know of (and that is certainly being quoted in wide circulation) comparing the effectiveness of the two was funded by the makers of Prilosec and Nexium, comparing healing rates of acid-reflux esophagitis with "typical" doses of Prilosec and Nexium. Nexium outperformed Prilosec in healing the worst grades of esophagitis - grades C and D. The "typical" doses used were 20 mg of Prilosec and 40 mg of Nexium. As this is the evidence out there, many doctors consider Nexium to be a "stronger" or "better" acid suppressor than Prilosec. I'll let the reader make the logical conclusions.
And let's talk about "typical" patients and the dearth of them in the evidence record. On an inpatient service today, I saw a "typical" patient hospitalized for a hypertensive emergency. He was a type 2 diabetic (DM)(uncontrolled) who came in with a blood pressure of 180s/120s. He has diastolic congestive heart failure (CHF) from his long-term uncontrolled hypertension (HTN). He also has chronic kidney disease probably due to a combination of his smoking, his DM, and his HTN. He also has an exacerbation of his bad chronic obstructive pulmonary disease (COPD) from his smoking. Now the evidence suggests that I place him on a beta-blocker to treat his HTN and his CHF concurrently. But beta-blockers are relatively contraindicated in acute exacerbations of COPD. The evidence suggests that I place him on an ACE inhibitor to treat his DM and HTN, but that would decrease his kidney function, and he's already at the tipping point of needing dialysis so
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 problem is that the market has come up with an awful solution to medical liability, which is pitting malpractice insurance against health insurance. Much of the cost of health care can be traced back to either. The other source of cost is that health care is sold as any other product on the free market, which is unfortunately very stupid. Deregulation of health care has led to the closure of hundreds of hospitals around the country, and pushed the costs out of the reach of much of the population. This is actually based on market principle, since the question moved from how much it costs to provide adequate health care, to how much people are willing to pay for it. Of course the upper sector of society is loving life with 3d pictures of their unborn child and access to obscure specialists at the drop of the hat, while the rest of the population struggles to pay for pills and basic care.
Now you have people dropping dead of overdoses and mixed prescriptions since the doctor is motivated to treat instead of heal, and billions of dollars are invested in figuring out how to sustain erections instead of preventing cancer. Hopefully the current economic situation will provide enough pressure to put an end to the ridiculous and unfounded belief that the market works for everything. Health care is no different than any other bit of infrastructure. You pay taxes and share risks for the benefit of the whole population.
Stronger dose placebos cost more:
http://www.walgreens.com/library/finddrug/druginfo.jsp?pdid=1088&particularDrug=Cebocap
Cebocap #3 (a prescription placebo) costs more than Cebocap #1.
No, anecdote implies that the information is second-hand, can not be verified, and is therefore unreliable.
Actual scientific data is first-hand and verifiable.
The current evil incarnation of HMOs et al were the result of a misguided and illiberal government policy: let's insure people through their employers. No employer meant either you are too rich for the government to care, or poor enough to be eligible for Medicaid. Self-employed? Sho-sho-shoo, we don't like these people — they are harder to corral.
Losing a job meant losing health-insurance, and switching employer often meant having to switch an insurer, along with the "network" of doctors. Why exactly the two completely unrelated things (job and health insurance) had to be bundled together by government regulation (employers were given a tax-credit for insuring the employees) remains unclear.
Last fall, however, during the elections, two alternatives were put forth. One of them, from Mr. Change, was the old and tried (elsewhere) "single-payer". He said, it is his top choice, but promised not to push for it, although health-related parts of the "stimulus" bill suggest the opposite.
The other proposal came from McCain, who wanted to eliminate the employer's tax-credit (the part Obama emphasized during debates) in favor of giving each individual a tax-credit (the part Obama never acknowledged) to be spent on their own health care. This would've created the same kind of market for health insurance as exists for, say, auto, term-life, house, and other insurances. The decoupling of health care from employment would've been much more fare, and the prices would've come down because of genuine competition.
The benefit would've been enormous, because the exelsior ("ever upwards" lat.) health care costs (and the associated evilness of health-insurers) are primarily explained by the fact, that consumers of care aren't the ones paying neither for the care itself, nor even for the insurance. This creates a lot of waste, and leads to — inefficient, but alienating — attempts to control it. Nobody is happy and we may end up with something worse (like government-provided health care), just because it will be different ("Change" is good, right?).
In closing I'd like to offer a real-life example... A doctor gave us a prescription recently for our newborn's acid reflux with the words: "try this, see if it helps her". The prescription was for 30 tablets (30 days). When I got to the pharmacy, I learned, that the 30 tablets cost $190, and that insurance will only cover $120 (for some reason or the other). Here is the point, where different people would think different things:
As you could guess, my thoughts were 2 and 3. But you, likely, know quite a few people, who would think 1 — and, maybe, 2 as well, but angrily.
In Soviet Washington the swamp drains you.
You're right about that not being the relevant question. The relevant question is:
Why is this included in an ECONOMIC STIMULUS PLAN?
3 things about computers: they're alive, they're self-aware, and they hate your guts.
Where are you getting this "half a semester's tuition" figure? A visit to a doctor's office doesn't cost any more than a visit to a hair stylist, and it takes a lot less time. You can fill a prescription for three months' worth of painkillers at Wal-Mart for $10.
I honestly don't get it. If your car got a bad flat you'd buy a new tire. You'd tell yourself "I have no choice." But when it's your own body that breaks down, instead of paying to get it repaired, you'd rather complain about it and act like you're a hero for enduring the injury. As a result, you'll probably end up with advanced arthritis at a young age and you'll never regain full physical function. Way to go.
Breakfast served all day!
There's another problem with anecdotal evidence -- selection bias. Some anecdotes are amenable to rigorous investigation and verification; when that happens they get called case studies instead. They're very useful, but they're not the same as broad-scale survey data, even when available in large numbers. The interesting cases turn into anecdotes, the boring ones get ignored, resulting in various forms of selection bias.
Anecdotes can tell us that something is worthy of further study. In order to conclude (for example) that PSA tests are meaningful, we need a statistically sound sample including people who both did and didn't get PSA tests. Even when the anecdotes are well researched and verified, their plural is not data.
As Paul Krugman said it, with the economy in this kind of state, you have to pay people to dig holes and fill them back up. If something good can be done instead of something useless, that's just a bonuns.
I sure as hell am not going to go through 10 years of schooling and assloads of debt just to make a wage I could have made with 4 years of school.
M.D.s get 4 years undergrad, 4 years med school, and a few years residency. They follow the standard of practice as they learned it with starting salaries around $100k/year.
Ph.D.s get 4 years undergrad, 5-6 years grad school, and a few years postdoc. They advance the state of art, train the physicians, and the engineers, and everyone else, with starting salaries around $60k.
Money is not the only motivator, and if you make it the major motivator, they you're not going to attract talented, well-educated people. You're going to attract people who are motivated by money.