08 October 2009

Unsubstantiated medicine

Half of the medical services in America do not have a good scientific basisKarina Nazaretian, for STRF
We are used to fully trust most medical procedures and medications.

But a considerable part of them is based on poor–quality scientific research, and even the flu vaccine is no exception, says Shannon Brownlee, a well-known American journalist who writes about medicine. Her work has appeared in such publications as The Atlantic Monthly, the New York Times, Time, US News and World Report, The New Republic, the Washington Post, the Los Angeles Times, etc. Her book "Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer" ("Overtreated: Why Too Much a lot of medicine makes us sicker and poorer") was named the best economic book of 2007 by a correspondent of The New York Times. Shannon is the winner of several prestigious journalistic awards, such as the 2004 Medical Journalists Association Award, the Victor Cohn Award for Excellence in Medical Science Journalism, and others. Shannon has a master's degree in biology.

When and how did you come up with the idea that the American nation was "overtreated"?I spent seven or eight years writing articles about "breakthroughs" in medicine for the magazine US News and World Report (this is one of the three largest news magazines in America, the other two are Time and Newsweek).

Over time, I began to write about medicine more critically. And here's what's interesting: my editors didn't like critical articles. They liked the articles that said: everything is great, this new medicine will save everyone's lives... And in 1999 I quit – partly because I was tired of writing the same stories all the time. I became a freelancer and did more and more critical articles. And then I came across some very interesting data.

This was a study conducted by scientists at Dartmouth College (Dartmouth College). They released the "Dartmouth Atlas of Healthcare". I got acquainted with their data and some other statistics – for example, about life expectancy and how it has changed in the United States over the past 50 years. And the question began to torment me: why are we spending so much money on healthcare, and life expectancy, for example, is not particularly increasing. And then I started studying to what extent medicine and healthcare really help people, and how much it's just a waste of money.

I heard that one of the editors even told you that he didn't believe you. Was that exactly what happened in 1999, when you quit?It was in 1998.

It was about an article about a test for early detection of prostate cancer (PSA testing, prostate-specific antigen testing), which is very widely used here in the USA (not so in Europe). Men who do not have symptoms of prostate cancer take this test, and sometimes the test shows that they have an early stage of cancer, and then they begin to be treated. People take it for granted that this is good, and I wrote in the article: listen, maybe this is not so good, because there is no evidence that this treatment really helps. But it has a lot of side effects, really serious. And so my editor at US News didn't like the article very much. I think he was just one of the "believers": this test should be effective, and if so, why am I writing this stupid article? And then, probably, for the first time I thought that the American press – I don't know if the situation is similar in the European press – but the American press has always done a lot of free advertising to medicine and healthcare, publishing such positive articles.

And after that you decided to become a freelancer?Yes, about a year after that.

In those last two years, something else has happened at US News. Since I have a scientific education and I know what good science is, I have always assumed that medicine is based on a good scientific foundation. And it was a shock – a really big shock – to find out that many things in medicine do not have a good scientific foundation at all, some things do not have anything scientific at all, and many are based on very weak, useless scientific research.

You once said that up to 50% of medicine in the USA is based on weak science…Yes, at most half of what doctors do – all examinations, procedures, operations, treatment – is based on serious scientific research.

The other half is what they were taught, or what they used to do, or what some very respected doctor spoke well about…

Even with medicines, the same situation. Although we have a strong regulatory body – the US Food and Drug Administration – which requires pharmaceutical companies to conduct scientific quality tests of their medicines. But even these tests are often not very strong from a scientific point of view.

And how do you know if they are strong or not?From two sources.

First of all, sometimes they are so bad that even I can see it. I am not a big expert in medical research, but I can look at the work and see, for example, that what is said in the main part of the article – the results section – does not coincide with what is written in the resume. The summary may say that the medicine is fine, and in the main text – that, well, not so great. And we know that most doctors only read resumes. Most often they do not read carefully into the article itself, and they are left with the impression that the article says: the medicine works wonderfully and has no side effects, while if you read it, there is nothing there. Now, sometimes even I can see that. But secondly, I have a number of familiar specialists who are perfectly able to analyze research and look for weaknesses in them. I trust their opinion. And then I can come to the authors of the study and say, "Guys, this is what those experts said about your study, what will you answer to this"?

And what do they say?They are trying to protect their results.

Next month, an article is published in the Atlantic Monthly magazine, which a colleague and I have been working on. It's about swine flu, a vaccine and flu medications. And it's really amazing how many people, for example, are sure that medications are effective, while this is not the case at all.

And this estimate – 50% of medicine based on weak science – is it approximate?It is inevitably approximate, but it is not taken out of thin air.

These are data from the Institute of Medicine, a very prestigious non–governmental organization in the United States that gathers experts of the highest rank. They made this assessment: at best, half of what doctors do in the United States is based on serious scientific research.

Could you give an example of how "bad science" is being put into practice today?Oh, yes. American hospitals are now purchasing a CT scanner, the so-called "64-slice CT scanner".

This is an amazing machine that can do computed tomography of a beating heart and create a three-dimensional image of the heart. Most importantly, in this three-dimensional image, you can see the coronary artery and see if there are any seals in it. Many cardiologists are crazy about this invention, and they plan to use it to work with everyone, including those who have no visible heart problems. But the machine is very expensive, and there are no studies that would show that using it to work with people without visible heart problems will help them become healthier. In fact, there is every reason to assume that using it to work with people without heart problems – for example, with those who have never had a heart attack – will lead to them being treated unnecessarily. Some radiologists and cardiologists say, "We need to do research, and only then use this machine," while others say, "Oh, no, it's so beautiful, we can't wait for research to be done." (Actually, a couple of studies were conducted, but they were very small and did not provide answers to fundamental questions.)

Another example of something that is widely used, but does not have sufficient scientific justification, is the flu vaccine. It is reasonable to assume that excellent studies and tests have been conducted here, which have shown that the vaccine is effective. But there is a group of experts called The Cochrane Collaboration – an international community of specialists in the field of statistics, research organization, virology – from various fields. And that's what they do (they call it "systematic reviews"): they take all the available literature on a particular issue and study the results of all the studies conducted, and then decide which studies are strong and which are weak. Then they look at what is said in strong studies (they make some extract from all good studies) and come to some conclusion: either we do not have enough information to evaluate this type of treatment; or we have enough information that shows that it is ineffective; or we have enough information that shows that that it is effective. So, The Cochrane Collaboration conducted a systematic review of all studies related to the flu vaccine. And we found out that, in fact, there are very few really good works on this vaccine. And from the good ones, it is unclear whether it is really effective for those groups of people who need it most: elderly and sick people. And it's amazing because we take it for granted that the flu vaccine is effective.

Today's pandemic in our country, most likely, will not be a big problem, because the swine flu epidemic is now milder than the usual seasonal epidemic. But if another flu appears, such as in 1918, it will be a disaster for the whole world. And we need research that would show whether the flu vaccine is effective.

I heard you talking about the site www.healthnewsreview.org . Are you one of its founders?No, this site was founded by a man named Gary Schwitzer.

He used to work as a correspondent in the CNN health department, and now is a professor at the University of Minnesota.

On this site, a group of experts analyze the news and articles appearing in the media concerning medicine. For journalists, this is a very useful site for a number of reasons, one of which is that it helps to understand how to make really good material. In addition, my colleague Jeanne Lenzer and I have a list of experts who help us: they can look at this or that study and say how good it is. And any journalist who would like to receive this list with contacts can write to us and we will send it to him.

And how do you know that these experts are impartial?Well, we can't say they're impartial.

All we can say is that they do not have any financial relations with manufacturers of medicines and equipment. Of course, they have their own preferences, but they are not involved in a conflict of interests. And this is a very serious conflict in American science and medicine. This is a very big problem, and it is obvious that this kind of financial relationship has repeatedly resulted in unreliable, low-quality, biased research. Especially in cases where a pharmaceutical company controls the preparation of a study, or its analysis, or publication. And they often do. They are trying to do their job – increase sales, increase the value of their shares. But this is not the same as doing balanced science.

Do you think it is possible to make an international version of this site, with experts from different countries?It's a great idea.

I'll talk to Gary about it. It would be very interesting to try to do this.

How do you assess the quality of American medical journalism compared to medical journalism in other countries?It's hard for me to say because I don't know other countries very well.

This is a terrible problem for Americans: we are very provincial.

Are you generally satisfied with medical journalism in the United States?No, I think she is very much lacking in depth and critical approach to problems.

This is partly due to the fact that it is very, very difficult to write critically about medicine. Personally, I can do this because I have been doing this for a long time, I have a database of experts who help me, I have a colleague who is well versed in medicine, Jean Lenzer. We work together. She knows the scientific side of things much better than I do, and I write better, and together we find ways to create really strong materials. But few medical journalists in our country have enough knowledge and experience to criticize.

Medicine in the USA has a very privileged position. Everyone has always believed that doctors do everything right and are always ethical. And they are not always ethical and do not always do everything right. Therefore, it is very important that the media take a step back and try to highlight the dark corners of medicine and healthcare. And there are a lot of dark corners. But you need to be very competent to illuminate these dark corners. I'm 53 years old, I've been doing this for a very long time. And it's still very difficult for me.

And if a person does not have a biological education, then, probably, it is impossible at all?It's very, very difficult.

You can learn in the process of work, but you need to be very smart and work very hard to learn to understand science and find a critical approach. Because doctors and medical researchers most often have a lot of power and a big ego, and it is very difficult to challenge them. If you don't have a science education, you have to learn how to find the right people who can challenge instead of you. And then you will make the material by talking to both them and those people who sell some new and supposedly miraculous medicine.

It's funny because in other areas of journalism – for example, in political journalism – you don't trust the person you're talking to, you assume that he may have motives to lie to you and say what he wants to see in print. And in medical journalism, for a long time it was believed that in medicine, everyone is wonderful and truthful and acts only in the interests of their patients. Some are really like that, but many medical journalists for a long time simply did not even question it.

What do you think about the healthcare reform that is now starting in the United States?I think this is the first step: we need everyone to have health insurance.

At the next stage, it will be necessary to change the way the treatment of people is organized now. Now everything is chaotic and uneconomical. Doctors carry out medicine of the XIX century with the help of technologies of the XX century. The next step in our healthcare reform is to ensure that the maximum number of hospitals and doctors follow the example of those few who are now working effectively.

Has your work ever led to any practical results?I have articles that once led to some changes in legislation.

But I think my book "Overtreated" has influenced the way people think about medicine and healthcare now. When I just started writing a book 5 years ago and talked about what it would be about (about excessive medical care), they looked at me like I was crazy! Everyone was sure that the problem was not excessive medical care, but a lack of medical care for those who do not have health insurance. And now many in our country understand that there is a problem of an overabundance of medical care, there is a problem of "overtreatment". I think I partially contributed to this, and I'm proud of it.

Portal "Eternal youth" http://vechnayamolodost.ru08.10.2009

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