The Doctor Will See You Now Page 3
As devastating as a diagnosis of breast cancer can be, it offers a new perspective on life; it is not all sadness. Patients, family, and friends can have many good moments during the course of the disease. Often they tell jokes together and experience a spirit of camaraderie they might otherwise not have known. Resist any urge to blame yourself for the disease. Remember, some things that happen cannot be prevented. (The two most important breast cancer risk factors, age and family history, are both beyond the power to control.) With the current progress in research and treatment, there is every reason to believe the prognosis for all patients will continue to improve. Finally, keep in mind the things that are truly important—your health and that of your family and friends.
5
ACHING FOR SOME UNDIVIDED MEDICAL ATTENTION
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I know I’ve made some very poor decisions recently, but I can give you my complete assurance that my work will be back to normal. I’ve still got the greatest enthusiasm and confidence in the mission. And I want to help you.
—HAL 9000 IN 2001: A SPACE ODYSSEY
IN STANLEY KUBRICK’S classic film 2001: A Space Odyssey, the survival of astronauts on a space mission depends on a computer, the infallible HAL 9000. HAL relates to the crew in human fashion and keeps them safe until the chilling climax when he decides to engineer their murders by sabotaging the ship’s life-support systems. It is the quintessential depiction of the erosion of trust between man and machine.
The medical profession currently faces the same existential crisis. Since being introduced into hospitals, computers have advanced medical care tremendously, but now they represent a serious threat to depersonalize the patient. According to a study in the Journal of General Internal Medicine, doctors in training currently spend only 12 percent of their time in direct patient care compared with 40 percent of time spent in front of computers. Moreover, this trend of reduced interaction with patients is growing worse.
It would be tempting to ascribe this development, like so much else in our contemporary culture, to a generational shift in attitudes. As one medical resident told the New York Times, “My generation is different because we can’t have the same relationships with patients as you did. We just don’t have the time.”
A nice, facile explanation, but this problem is hardly confined to young trainees. Virtually every attending physician I speak to, including some in their seventies, describes the unsettling number of hours they must spend in front of the computer at the expense of time with the patient.
Nor is this development limited to physicians. Today’s modern hospital furnishes nurses with portable computers to enter patient data, write notes, and scan medications. Presumably more efficient, but unquestionably less personal. Nurses, like their physician counterparts, have become more high tech, less high touch.
The resident who spoke to the New York Times unwittingly fails to appreciate the twofold problem the current situation presents. First, to become proficient a doctor or nurse must train all five of their senses, which the computer discourages. One must learn to observe by actually looking at the patient. Likewise, learning to talk to the patient, what to ask, as well as when and how, cannot be replicated by a software template of questions.
Hearing is also a skill that must be cultivated—it’s more than just listening to a stethoscope (or today an ultrasound); it’s listening to what the patient has to say. Touch is important, everything from taking the pulse to palpating masses. And smell can be a means of diagnosis; there are even diseases that can be diagnosed the moment you walk into a patient’s room. Staring at a computer screen and tapping on a keyboard might approach but will never reproduce all these things.
But even more significant than acquiring technical proficiency is establishing human contact. The essence of the medical profession is showing patients you really care by creating a personal bond—the manner in which you talk to them, listen to them, and touch them sympathetically and make eye contact. (Tellingly, in 2001: A Space Odyssey, HAL’s lack of human emotion was portrayed by its electronic laser eye, which gave the astronauts nothing to make eye contact with.) No one expressed the essential nature of human contact better than Sir William Osler, considered the preeminent clinician of the twentieth century, who advised the young doctor, “Care more for the individual patient than for the special features of the disease. . . . Put yourself in his place. . . . The kindly word, the cheerful greeting, the sympathetic look—these the patient understands.”
Contrast the twentieth-century Oslerian philosophy with the twenty-first-century philosophy expressed by former secretary of health and human services Kathleen Sebelius. In 2010 in Kaiser Health News, she wrote, “Over the last 30 years, we’ve watched information technology revolutionize industry after industry, dramatically improving the customer experience and driving down costs. Today, in almost every other sector besides health, electronic information exchange is the way we do business. A cashier scans a bar code to add up our grocery bill. We check our bank balance and take out cash with a debit card that works in any ATM.”
This analogy betrays a fundamental misunderstanding of the art of medicine in any century. Grocery bar codes and ATMs are efficient, albeit depersonalizing examples of technology affecting our lives. But the ideal goal of medical care is to be able to spend more, not less, time with and attention on patients.
Bedside manner is on its deathbed. It can be saved only if the medical community, the tech community, and the government address the proper use and abuse of computers in medicine. The alternative is that in the future patients will be citizens of a dystopian brave new world where anyone may be able to see the doctor, but the doctor won’t be looking at them.
6
REPORTING SCIENCE
WITHOUT THE DRAMA
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News Items: 25,000 U.S. DEATHS LINKED TO SUGARY DRINKS.
1 IN 10 U.S. DEATHS BLAMED ON SALT.
DRAMATIC HEADLINES, but questionable science. As with other media science coverage, the response left much to be desired. Researchers’ findings are often misinterpreted. That’s in part due to conclusions that journalists routinely draw but that tend to short-circuit full analysis. The following are all common pitfalls:
The simpler the association, the better. The assertion that twenty-five thousand deaths are annually linked to excess sugar intake is an example of an overly simplistic conclusion attributed to cause and effect. This ignores a host of complicating variables that confound the relationship between diet and mortality (other diseases, genetics, alcohol, tobacco). Even the well-established but incompletely understood association between tobacco and lung cancer is not direct cause and effect; many smokers do not develop cancer, and some nonsmokers do. Despite the facile headlines, cause-effect relations are almost never clear-cut.
Reporting abstracts rather than peer-reviewed studies. Both the salt study and soft drink study are abstracts—preliminary reports that journals and professional societies introduce before peer review. The findings of an abstract have not been subjected to rigorous outside analysis. Publicizing abstracts conveys undue importance before the work has undergone scientific scrutiny. An abstract is to a finished study what a screenplay is to a movie—an essential first step that sometimes yields a finished product, even an occasional blockbuster, but often winds up on the shelf.
The allure of large, round numbers. In 2016 the city of Chicago estimated the attendance along the parade route and at the Grant Park rally for the Chicago Cubs’ first championship in over one hundred years was about five million people. The actual number cannot be counted, and reliable estimates require considerable time, effort, and expense. Consequently, a large, round number, accurate or not, is published. A ready example is the widely cited figure, albeit with a shaky foundation, of how hospital errors are responsible for one hundred thousand deaths annually. Originally derived from a 1999 Institute of Medicine estimate, rather than direct observation, the published number was actually a range o
f forty-four thousand to ninety-eight thousand. The large, round number entered the public domain when sources simply accepted the higher estimate and rounded up, even though the actual figure is unknown and may be far less—closer to or perhaps even below the lower limit of forty-four thousand.
Academic imprimatur. Studies done at prominent research centers generally receive greater attention than those from less prestigious ones. This is expected—Harvard has more experienced researchers, and more research dollars, than Southwest Technical State. However, Harvard research is not intrinsically more valid. This is fallacy of authority—a Harvard study receives more publicity and less scrutiny.
Respected journal. Authority fallacy also occurs because journalists are loath to dissect studies from prestigious journals. In 2006 the Lancet, one of the world’s top medical journals, published a Johns Hopkins study indicating an excess of six hundred thousand civilian deaths in the first three years of the Iraq War, a finding that seemed implausible on its face. The high death rate meant over five hundred more civilians died each day during the war than before it, a fact that could not be confirmed independently by either the United Nations or the Iraqi government. Widespread, unquestioning television and newspaper coverage of the controversial figures followed, in large measure due to publication in the Lancet. However, there was little press follow-up of subsequent analyses by other researchers demonstrating important methodological flaws and ethical questions in the original study. Their research suggested the first study may have overstated civilian casualties by several hundred thousand.
Studies from prestigious-sounding organizations. Reporters gravitate toward studies from “institutes,” “foundations,” and “schools of public health policy.” While these studies are quite often reliable and well done, there is an inherent danger that many of these organizations have a political agenda, whether liberal or conservative, which could be reflected in their work. Individuals who join these organizations may perform research that promotes, either consciously or unconsciously, the organization’s biases.
A persuasive spokesperson. Think of it as the Walter Cronkite effect. The authors of a study may dispatch a spokesperson, usually an articulate, knowledgeable researcher, to enhance the study’s credibility with the press. Journalists, often with little scientific background, are unwilling or unable to make appropriate inquiries about the study’s findings. In this way a study’s flaws can easily remain undiscovered.
Publication bias toward positive effects. In reporting scientific studies, the media are prone to cherry-picking—that is, publishing studies that have successful outcomes or suggest an actual effect (such as salt consumption causing death). Scientific journals often exhibit the same bias. In 1991 Canadian researchers analyzed how North American newspapers approached two studies on the association of radiation and cancer, one showing a positive association, the other failing to find one. They concluded, “The number, length and quality of newspaper reports on the positive study were greater than news reports on the negative study, which suggests a bias against news reports of studies showing no effects or no adverse effects.”
Do any of these factors by themselves mean media reports about science are necessarily wrong? No, but science is inherently complex, and media coverage often proves Oscar Wilde’s observation that the truth is rarely pure and never simple.
7
DR. OZ, HEAL THYSELF, AND “BROADCAST DOCTORS” ON TV
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Medicine grounds me, it centers me, that’s why I continue to do it.
—DR. MEHMET OZ
HAS DR. OZ JUMPED THE SHARK? With millions of television viewers and disciples, he is unquestionably the most popular physician in the United States, if not the world. But because his commentaries have begun deviating from traditional medical advice into the realm of unproven natural medicines, nostrums, and occasionally even further into homeopathy and faith healing, that hard-earned popularity has come at a cost to his reputation, especially in the medical community. It says much about medicine on television.
For nearly thirty years, Dr. Oz has been a well-respected cardiac surgeon at one of the country’s top medical centers. He has a smooth, poised demeanor on television. Yet in 2014 during his appearance to testify before the Senate Commerce Committee about his testimonials of untested weight loss drugs, he came off looking more like a flustered criminal underboss than a confident surgeon who has deftly operated on hundreds of human hearts.
Much of the advice Dr. Oz dispenses on his television show and his website is grounded in solid science, and his unpretentious approach is immensely popular with the general public. But at virtually every medical center I have visited recently, I notice him being roundly criticized by doctors for his forays into alternative medicine and his increasingly nonscientific approach. No doubt some of this is based on jealousy; some of those doctors would love the exposure and fame he has. But this does not explain it completely. Much of the criticism is legitimate and is getting louder.
Dr. David Gorski, an MD/PhD who is a surgical oncologist in Detroit and the managing editor of the medical blog Science-Based Medicine, has been especially critical of Dr. Oz in his blog. He writes, “I keep hoping that someday he’ll have an epiphany and realize he is no longer a scientist. Worse, he is no longer a responsible doctor. Instead, he’s become an enabler and cheerleader, either wittingly or unwittingly, for quackery.”
Several years ago, Benjamin Mazer, a medical student at the University of Rochester, began a public campaign against Dr. Oz. He requested state and national medical societies scrutinize Dr. Oz’s advice more closely. He told the website Vox,
Dr. Oz has something like 4-million viewers a day. The average physician doesn’t see a million patients in their lifetime. That’s why organized medicine should be taking action. . . . I’m definitely not the only one. This issue was brought up by a number of physicians I worked with during my family medicine clerkship. We had all of this first-hand experience with patients who really liked his show and trusted him quite a bit. [Dr. Oz] would give advice that was really not great or it had no medical basis. It might sound harmless when you talk about things like herbal pills or supplements. But when the physicians’ advice conflicted with Oz, the patients would believe Oz. . . . Many patients trusted Dr. Oz more than their own family doctors and this conflict hurt the doctor-patient relationship. The trust people are placing with Dr. Oz—when their family physicians even nicely try to contradict him—disrupts their relationship.
Long before Dr. Oz, reality television, and the current glut of TV shows featuring doctors and nurses something of a bright line existed between show business and medicine. Your TV might feature fictional heroes—Ben Casey, Dr. Kildare, or Hawkeye and Trapper John—but real physicians rarely went on television. Ironically, among the only times in the early days of television that actual doctors were mentioned were in cigarette endorsements.
That was then, but now the bright line has vanished. There is no longer any need for disclaimers. Today television loves medicine, with fictional doctors and nurses in situation comedies, detective dramas, and soap operas. Meanwhile real doctors are medical reporters, talk-show guests, and infomercial hosts touting pharmaceuticals and hospitals.
In a well-publicized incident on his syndicated TV show in 2011, Dr. Oz released research showing that some brands of apple juice contained unacceptable levels of arsenic. This drew the ire of the Food and Drug Administration (FDA), which roundly criticized Dr. Oz and reasserted its findings that apple juice is safe to drink.
Dr. Oz, however well intentioned, left himself open to criticism on several points. His research failed to distinguish between toxic and naturally occurring arsenic, the latter widely believed to be harmless. He failed to repeat his studies in a second lab to reconfirm the disturbing results, which would be the logical next step of scientific analysis. Finally, he avoided the question of whether any children had actually suffered arsenic toxicity. Quite to the contrary, he reassured vi
ewers they could continue to let their children drink apple juice, rather surprising advice in the face of what he believed were toxic arsenic levels.
Nevertheless, Dr. Oz deserves credit for demanding accountability from the FDA. He rightfully asked the FDA to be more transparent in its analysis of apple juice and, by extension, in its entire process of food testing. Transparency has been an issue for the FDA in the past, and thanks to Dr. Oz the agency issued new rules on arsenic levels in apple juice to avoid a public health scare.
The question of apple juice toxicity demonstrates the mixed blessing in the marriage between medicine and show business. Besides raising the public health consciousness, television medicine creates more educated consumers. People can now receive what amounts to a near equivalent of a premedical education served up on television. Does this plethora of diagnoses, surgery, and drugs on the tube serve the public well?
In many respects, yes. Many patients receive screening and therapy more promptly than in the past, they ask better questions when being examined, and occasionally they are able to alert the doctor to conditions and treatments the doctor may not have considered. Show business can, and occasionally does, save lives.
But the benefit is not unalloyed. The flip side is that television can mislead the public (witness the FDA brickbats, legitimate or not, thrown at Dr. Oz). There is a mutual exploitation between television and medicine. Television, in its eternal quest for ratings, invariably trolls for what’s new, exciting, and trendy. This often distorts reality in a manner antithetical to the nature of medicine, where knowledge is often accrued gradually and it often takes years to prove a treatment’s effectiveness or danger.