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TV turns doctors into blithering idiots
Posted: 07 October 2011 06:33 AM   [ Ignore ]
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I’ve already been on the record as a Dr. Oz anti-fan, but it continuously amazes me that nearly every physician who gets in front of the TV camera seems to let reason and objectivity fly out the window as soon as their on the air. The recent announcement by the USPSTF recommending against PSA testing is what prompts my observation but its something I’ve noticed for a long time.

Yesterday the United States Preventative Services Task Force made a long overdue recommendation that doctors and patients think long and hard before routinely ordering a PSA test to screen for prostate cancer. The interesting thing is that we have known for nearly 20 years that this test did little to improve survival rates for men who develop prostate cancer. Now 20 years after multiple studies have confirmed this we finally have an announcement from a well respected organization made up of experts in the field and what happens? Nearly every “TV doctor” ( with one shining exception) blasts the expert panel that made the recommendation. I saw one physician actually take the report and tear it up in front of the camera to demonstrate his “disgust” with it. None of these doctors gave a rational reason for disagreeing with the report. Several fell into the same trap that non trained individuals do by siting anecdotal examples which prove nothing.

The same thing happened a number of months back when physicians from the same group recommended against mammograms in women under 50 based on good scientific evidence that they are of little benefit and may result in more harm then good. Again, something we’ve known for many years and something that needs to be addressed logically and reasonably.

There are two issues here really. Doctors are people and many of them are not necessarily rationale thinkers just because they went to medical school and studied science. They fall into the same trap as non-scientists. They see a patient, do test, discover a disease, treat the disease, the patient lives, and they assume that their intervention saved the patients life when in reality it may not have changed the course of the disease at all.

The second issue though is what happens when doctors get in front of a TV camera and get a large audience. I think they become so enamored of the idea of becoming famous that they quickly learn that the way to do that is to tell people what they want to hear. People want to believe that screening and early detection can save lives. Its unsettling to learn that in many cases thats not true. They are fearful and suspicious when a government agency suggests that we should stop offering these tests and the TV doctors wanting to look like the good guys and increase their viewership, march to their defense and decry these new recommendations in dramatic fashion ( like tearing up the report)

The one shining star among these physicians has been Dr. Richard Besser. He used to head the CDC and now works for ABC. He most recently butted heads with the “wizard of Oz” over the Apple Juice Arsenic scare ( a scare fabricated by Oz). He has been on TV today trying to lend a voice of reason to the PSA debate and has been doing a pretty good job. Unfortunately he is the one voice among a cacophony of physicians who seem to have forgotten what they studied in med school or forget it as soon as they say “you’re on the air”

[ Edited: 07 October 2011 06:59 AM by macgyver ]
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Posted: 07 October 2011 08:11 AM   [ Ignore ]   [ # 1 ]
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Well, yeah. Everyone has those pesky cognitive biases.

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Posted: 07 October 2011 09:45 AM   [ Ignore ]   [ # 2 ]
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I think if it was just the cognitive biases it wouldn’t bother me as much although as physicians and semi representative of the scientific community they should be held to a higher standard. They should be called to the carpet when they don’t meet that standard, not praised and paraded around on TV. Its really the self serving, narcissistic nature of what they are doing that i find most difficult to stomach as a fellow physician. Those of us with opposing viewpoints don’t seem to get nearly the air time because the media loves the drama and these guys provide it and the public loves to the positive “self empowering” message that they are being fed by these guys. They give the public what they ant not because they believe it is helpful ( most of it is not), but because they know that if you give the public hat they want they will beat a path to your door and to them fame and fortune are more important than integrity.

Of course some of them really believe the misinformation they provide but stupidity is somehow more tolerable than a lack of integrity i think.

Sorry for the rant. I really should post this on a medical board, but I haven’t found a decent one yet.

[ Edited: 07 October 2011 09:53 AM by macgyver ]
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Posted: 07 October 2011 10:15 AM   [ Ignore ]   [ # 3 ]
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Unfortunately, like every other field, physicians have their share of ego-freaks and nuts.  While a normal doctor isn’t interested in publicity, these guys cause all sorts of problems because of the wide distribution of their misinformation. 

My PSA was run as a part of a complete panel about 12 years ago.  On checks it was rising and in what was considered a marginal range.  My urologist suggested three choices 1) Watchful waiting - the European way, 2) Surgery, 3) radiation.  I chose radiation and that was fine (except for the damned Aberelix which permanently reduced my testosterone level).  However, i agree.  The first choice would quite possibly have been better.

Occam

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Posted: 07 October 2011 11:03 AM   [ Ignore ]   [ # 4 ]
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I took the watchful waiting route until the curve of growth of PSA showed an accelerating upward curve. It was still below the danger level, but there was no reason to believe that it would stop accelerating, so I decided “What the hell, might as well cut the damn thing out now.” It was done laproscopically.

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Posted: 07 October 2011 11:18 AM   [ Ignore ]   [ # 5 ]
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Well now that Im done with my original rant perhaps its w more useful to focus on the PSA issue. Chris no one can fault you or your doctor for the decision that you made. It would certainly be difficult to ignore a rising PSA especially if it is followed by a biopsy that shows tumor cells. The point of the latest recommendation is that research seems to indicate that following that course doesn’t reduce your chance of dying from prostate cancer or prolong your life. The argument then is that perhaps we should not be putting patient and physicians in the position of having to make these decisions based on such an unreliable test. Not only does it lead to anxiety but many men are having unnecessary surgery and radiation that at the very least is uncomfortable, in many cases causes impotence, and in some cases leads to premature death.

To be honest, I usually due a PSA on my patients who are in the “appropriate” age range (40-75) although I don’t believe it should be done. The reason I do is that there is a certain expectation among men and their partners that it will be done, there can be legal ramifications if its not done even though it has no proven benefit ( Don’t get me started with our idiotic tort system), and it just takes too much time to have a discussion with patient about the pros and cons of the test since the argument goes against everything they believe ( although I am putting together a pamphlet to address this for patients to read prior to their exam). Insurance companies don’t pay for these sorts of discussions and it can easily add 15 minutes to each visit which is not something any physician can afford to do.

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Posted: 07 October 2011 12:42 PM   [ Ignore ]   [ # 6 ]
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I failed to mention the results of the operation:

The prostate was enlarged
There was a big malignancy in it
The malignancy had not yet breached the membrane of the prostate

My urologist seemed to think that, had we waited another year, the malignancy might have broken through the membrane, in which case the cancer would have metastasized. Is this hypothesis unlikely to be correct?

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Posted: 07 October 2011 09:49 PM   [ Ignore ]   [ # 7 ]
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Yes, it is frustrating that the very people most interested in, and successful at, getting publicity talking about medicine are often the least rational and least likely to offer a thoughtful, nuanced explanation or the complex realities of medical science. Perhaps I’m a bit bitter since there are literally hundreds of books and numerous satellite radio and TV programs by veterinarians pushing alternative nonsense, but in trying to push a Trick-or-Treatment style debunking of this, I’m repeatedly told there is no audience. Sheesh! But it seems like simplistic narratives and drama sell better than the tedious truth.

As for the PSA issue, it does seem like this isn’t really news. Harriett Hall at Science-Based Medicine wrote about the subject a couple of years ago, and it figures prominantly as a case study or overly broad screening in the recent book Overdiagnosis. As a proponent of evidence-based veterinary medicine, I would kill to have an organization like the USPSTF as a guide my profession, so it puzzles me that their relatively conservative analyses of the evidence is greeted with such drama.

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Posted: 08 October 2011 01:58 AM   [ Ignore ]   [ # 8 ]
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Don’t forget Dr Drew Pinsky; he’s a board certified MD, but his “relationship advice” is based on his own opinions, not science, and his hogging of the spotlight in order to showcase his treatment of drug addicts borders on medically unethical.

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Posted: 08 October 2011 01:21 PM   [ Ignore ]   [ # 9 ]
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mckenzievmd - 07 October 2011 09:49 PM

Yes, it is frustrating that the very people most interested in, and successful at, getting publicity talking about medicine are often the least rational and least likely to offer a thoughtful, nuanced explanation or the complex realities of medical science. Perhaps I’m a bit bitter since there are literally hundreds of books and numerous satellite radio and TV programs by veterinarians pushing alternative nonsense, but in trying to push a Trick-or-Treatment style debunking of this, I’m repeatedly told there is no audience. Sheesh! But it seems like simplistic narratives and drama sell better than the tedious truth.

As for the PSA issue, it does seem like this isn’t really news. Harriett Hall at Science-Based Medicine wrote about the subject a couple of years ago, and it figures prominantly as a case study or overly broad screening in the recent book Overdiagnosis. As a proponent of evidence-based veterinary medicine, I would kill to have an organization like the USPSTF as a guide my profession, so it puzzles me that their relatively conservative analyses of the evidence is greeted with such drama.

You’re right about this not being new. We’ve known that the PSA was not a very effective screening test for 20 years at least and yet it gets done regularly because the media promotes it and the public expects it. This is primarily the fault of my own profession, many of whom prefer to ignore evidence that doesn’t agree with their intuition. The odd thing is that the CA125 came out around the same time as a screening test for ovarian cancer and except for a few fringe websites and misinformed talk show guests no one puts any stock in this test. I’m not really sure why one test took hold and the other didn’t but changing public perception is key to diminishing the use of these tests.

The USPSTF really is a great organization. They have for the most part been devoid of political influence and bias. I’m not sure how much weight they hold in a court of law however when the opposing lawyer can site recommendations from specialty groups which may hold an opposing view and are more beholden to the desires of the public. The mammogram recommendation is a perfect example. The USPSTF last year recommended against mammograms in women under 50. This is in line with the practice of nearly every industrialized nation and every study done on mammograms. Unfortunately the USPSTF recommendation was met by tremendous resistance from the pubic and politicians and eventually from ACOG ( American College of Obstetrics and Gynecology). What should have resulted in an intelligent public discussion of an important matter that is costing us billions yearly and doing little to save lives developed into an angry backlash against the USPSTF and the conversation ended.

The USPSTF is a strong ally for evidence based medicine but until they can get the public and our representatives to understand their reasoning and agree with them physicians are stuck ordering tests that are useless, expensive, and perhaps even harmful unless they sacrifice large amounts of time to have often fruitless discussions with patients who are left feeling confused by the mixed messages they are getting.

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Posted: 08 October 2011 01:38 PM   [ Ignore ]   [ # 10 ]
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Chris Crawford - 07 October 2011 12:42 PM

I failed to mention the results of the operation:

The prostate was enlarged
There was a big malignancy in it
The malignancy had not yet breached the membrane of the prostate

My urologist seemed to think that, had we waited another year, the malignancy might have broken through the membrane, in which case the cancer would have metastasized. Is this hypothesis unlikely to be correct?

In your case, it appears to have been the correct action, but one case does not a study make.. wink

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Posted: 08 October 2011 06:14 PM   [ Ignore ]   [ # 11 ]
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Chris Crawford - 07 October 2011 12:42 PM

I failed to mention the results of the operation:

The prostate was enlarged
There was a big malignancy in it
The malignancy had not yet breached the membrane of the prostate

My urologist seemed to think that, had we waited another year, the malignancy might have broken through the membrane, in which case the cancer would have metastasized. Is this hypothesis unlikely to be correct?

Asanta is correct. There is no way to know what would have happened if you hadn’t been treated. Your urologist is subject to the same observational biases as the rest of us. His conclusion may be accurate and it may not be. Most prostate cancers are indolent. You may have lived to 80 and carried it to your grave ( not implying you’re going to cash it in at 80 by the way) without treatment. no one knows and thats the problem. We have no way to accurately detect and differentiate the aggressive prostate cancers form the ones that will never cause a problem and we don’t even know if we could alter the outcome if we could distinguish between the two.

Don’t second guess yourself though. You made the best decision you could with the information you had. With a little luck this will lever be a problem for you again.

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Posted: 08 October 2011 07:43 PM   [ Ignore ]   [ # 12 ]
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Macgyver - what do you think of the “Dr. Oz effect” regarding doctors prescribing HCG shots for weight loss. I hear at first Dr Oz said it was unhealthy, but then did a later show endorsing the diet (which is extreme 500 calories per day plus questionable fertility drug injections.) I now see billboards everywhere for doctors prescribing this diet.

Just last week, my nearly 70-year-old mother went to a new internist who - out of the blue - suggested the HCG shots and diet during a routine exam. (She does need to lose weight but I think that is extreme to suggest HCG to a senior citizen with lupus and other complications.) She refused.

Everything I’ve read says the diet is no better than placebo injections, and all weight loss is due to the extremely low calorie intake.

I also recently went to a new spa for massage and manicure, and they were pushing the HCG diet to my surprise! They referenced the Dr Oz endorsement, and told me the diet “melts fat while sparing muscle and stays off permanently” (which I chuckled out loud at.) Then they asked if I wanted to sign up because a local allergist who visits the spa once a week writes the prescriptions for the HCG.

I suspect this HCG is a big cash maker?

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Posted: 08 October 2011 09:44 PM   [ Ignore ]   [ # 13 ]
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First off, unless your mom is obese, and it is causing health problems, older women tend to do better in old age with a little extra padding; it decreases their incidence of hip fractures and gives them extra reserve if they come down with a serious illness needing hospitalization or surgery.

I loathe ‘Dr Oz’ mad he has prostituted his profession.

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Posted: 09 October 2011 01:53 PM   [ Ignore ]   [ # 14 ]
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Hey there Jules. Good to see you. Been a long time. Hows your photography coming along with the new ( well maybe not so new at this point) camera?

Asanta is right. There is no benefit that I am aware of to using HCG in a diet plan and at any rate doctors should not be promoting the use of hormonal treatments that have not been studied.
As far as Dr. Oz goes i need to clarify one thing. Oz may be well regarded among the public and especially among housewives who have nothing better to do at 4 in the afternoon but he is NOT someone that the rest of the medical profession looks up to. As Asanta has said he really has prostituted himself. He has abandoned the scientific method and evidence based medicine in favor of the “promote whatever increases your rating and helps sell your books” medicine. My advice would be to find something better to do at 4pm and find your mom a new internist. Doctors who are promoting these crazy diet schemes are mostly quacks who are looking for a fast track to a better income.

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Posted: 09 October 2011 09:25 PM   [ Ignore ]   [ # 15 ]
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Mac, if I remember correctly, there were possibly some nasty side effects due to unregulated use of HBG, but I can’t remember the story clearly. It has had NO double blinded studies to assess efficacy or side effects. There isn’t even a clear idea of what it would/could do to help anyone medically. And remember, anything with effects, also has side effects. Are they worth it? Would you take a medicine to lose weight if the side effect were liver damage or greatly elevated cancer risks? What if you only lose 5 lbs in the process? I’m not saying HBG has these side effects, but I am saying, things are a little more complicated that what the doctor is leading your mother to believe. I’d get another doctor.

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