How did we get here? How did we get to a place where doctors occasionally ignore thoughtful, carefully performed studies published in excellent journals and order tests or prescribe drugs or perform cancer screenings that have clearly been shown to do more harm than good? This problem isn’t exactly a well-kept secret. In 2017, The Atlantic published an article titled “When Evidence Says No, but Doctors Say Yes.”1 One year later, an op-ed in the New York Times read, “It’s Hard for Doctors to Unlearn Things: That’s Costly for All of Us.”2
So, again, how did we get here?
Sometimes doctors simply aren’t up to date on recent studies. Given the complexity and diversity of medicines and therapies, it’s not hard to see how this could happen. There are 6,500 medical and scientific journals in the world that publish about 4,000 studies every day. Not surprisingly, these articles follow a bell-shaped curve. Some are excellent. Some are awful. Most are more or less mediocre. It can be difficult to separate the good ones from the bad ones, especially for a busy clinician.
Doctors are paid for what they do, not for what they don’t do. “It’s hard to get people in any profession to do the right thing,” wrote David Epstein for the public interest group ProPublica, “when they’re paid to do the wrong thing.”3 This is particularly true for surgical procedures such as knee arthroscopies and heart stents.
Steve Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, offered one solution: eliminate financial incentives. “Things have gotten better but they’re not where they need to be,” he said. “I have a dozen or so cardiologists, and they get the exact same salary whether they put in a stent or don’t. I think that’s made a difference and kept our rates of unnecessary procedures low.”4
Regarding inappropriate testing, such as measuring blood levels of testosterone and vitamin D, Canada and Australia simply stopped paying for them. Within six months, the number of tests ordered dropped by 80 percent.5
In the United States, health care is a $3.3 trillion business. Unfortunately, it often acts like a business. Patients aren’t patients anymore; they’re clients. Customer satisfaction has become the coin of the realm.
Dr. John Christoforetti, a prominent orthopedic surgeon in Pittsburgh, shared an experience that is both sobering and typical. After evaluating a woman who wanted an operation to repair a small meniscal tear in her knee, Christoforetti explained to her and her husband that she didn’t need it. Physical therapy would work just as well. “She left with a smile on her face,” Christoforetti recalled, “but literally as they were checking out we got a ding that someone had rated us on a website and it’s her husband. He’s been typing on his phone during the visit, and it’s a one-star rating that I’m an insensitive guy he wouldn’t let operate on his dog. They’d been online and they firmly believed she needed this one operation and that I was the guy to do it. Most of my colleagues will say, ‘Look, save yourself the headache and just do the surgery. Your bank account’s not going to be upset with you for doing the surgery. Just do the surgery.’”6
Demand for unnecessary antibiotics is another example. In 2018, researchers from the Cleveland Clinic examined the relationship between patient ratings and receipt of an antibiotic prescription. The study included adults with colds and mild upper respiratory infections, the vast majority of which are caused by viruses and don’t benefit from antibiotics. The researchers examined 8,500 encounters with 85 physicians. They found that 91 percent of patients who received an antibiotic prescription rated their encounter with five stars compared with 73 percent of those who didn’t receive a prescription. To reach the top twenty-fifth percentile in patient satisfaction, physicians had to prescribe unnecessary antibiotics at least half the time; to reach the top tenth percentile, they had to prescribe them at least 75 percent of the time. The authors concluded, “No other patient or physician factor was as strongly associated with patient satisfaction as receipt of a prescription for an antibiotic.”7
Unfortunately, patient satisfaction scores often conflict with best medical practices. Doctors in hospitals are starting to act more like waiters in restaurants. (“Hi. My name is Dr. Smith. I’ll be your doctor today. Let me tell you about a few of the therapies that we have on our menu.”) Shannon Brownlee from the Lown Institute, an organization dedicated to restoring the doctor-patient relationship, wrote, “Calling patients consumers who need to be engaged reinforces an attitude that says that a person who is sick, frightened, in pain, and in need of care is no different than a consumer buying a used car.”8
Health care providers can best guide patients through the dense thicket of medical information by offering booklets, videos, tear sheets, and other educational materials instead of caving in to patient demands. Several physician groups, such as Choosing Wisely, the Right Care Alliance, and Slow Medicine, are now doing just that, offering easy-to-understand educational materials so patients can make the best choice for their health, even when it’s not the easiest or most popular choice.
Most physicians take pride in what they do. It’s hard for them to imagine that they’ve been doing something for years that might have been hurting their patients. Even in the face of overwhelming evidence to the contrary, established practices die hard.
In 2007, John Ioannidis and colleagues, in a paper published in the Journal of the American Medical Association titled “Persistence of Contradicted Claims in the Medical Literature,” found that even after particular claims had been dismissed by excellent studies, many publications continued to reference these older, unsupportable claims. For example, they examined the claims that vitamin E could decrease the incidence of heart disease; that beta-carotene, a vitamin A precursor, could prevent cancer; and that estrogen treated Alzheimer’s disease—all of which had been shown to be false. They found that it took about ten years before medical publications acknowledged that these claims were invalid. The authors argued that the reason it took so long was that doctors wanted the original claim to be true. They wanted to believe that they had been helping. “Sometimes investigator beliefs in scientific circles may have similar psychological characteristics as the nonscientific beliefs observed in other areas of society,” they wrote. “The wish bias of individuals irrespective of topic can be large.”9
Perhaps the best example of the physician’s desire to hold on to the belief that a disproven therapy is valuable is heart stents. In 2018, researchers in the United Kingdom randomly assigned patients with at least 70 percent blockage of a single coronary artery into two groups. One group received a stent to open up the blockage; the other underwent a sham operation. Called ORBITA (Objective Randomised Blinded Investigation with Optimal Medical Therapy of Angioplasty in Stable Angina), it was the perfect study. After the real or sham operations, both groups improved. Merely believing that you had had a stent placed improved exercise tolerance. Although doctors could reasonably argue about the ethics of this study, they couldn’t argue with the results. Nevertheless, they did.10
After publication of this trial, heart surgeons railed against the result. After all, heart stents made biological sense: a patient has chest pain; a doctor finds a blockage; removing the blockage should relieve the pain. As it turns out, it was more complicated than that. Blockage of a large coronary artery was also invariably accompanied by blockages of smaller branches downstream, which weren’t treated by the stent. Doctors wrote letters to journals and posted comments about the trial on social media. They claimed that the patients in the trial weren’t sick enough; or that a subgroup might have benefited; or that, in their experience, stents worked; or that the trial was unethical because everyone already knew that stents worked. One of the principal investigators on the trial, Darrel Francis, a British interventional cardiologist, wrote on Twitter, “I would like to thank the patients participating in #ORBITA without realizing what a low level of intellect would be put into criticizing their efforts.”11
In the 1950s, Dr. Paul Hawley, director of the American College of Surgeons, said, “[T]he public would be shocked if it knew the amount of unnecessary surgery performed.” In 1976, the American Medical Association called for a congressional hearing on unnecessary surgeries, claiming that every year, “2.4 million unnecessary operations [were] performed on Americans at a cost of $3.9 billion.”12 Unfortunately, surgical procedures are not highly regulated. Unlike drugs, surgeries aren’t subjected by the Food and Drug Administration to Phase I, II, and III studies where researchers have to prove in progressively larger clinical trials that their therapies work and are safe. We are well beyond the time when it would be of value to impose these regulations.
Between 1997 and 2016, spending on the marketing of drugs, disease awareness campaigns, health services, and laboratory testing increased from $12.7 billion to $29.9 billion a year. Direct-to-consumer ads alone increased from $2.1 billion to $9.6 billion. Disease awareness campaigns for bogus disorders such as “Low T” offer catchy, easy-to-remember acronyms (e.g., ED, for erectile dysfunction), quizzes that encourage self-diagnosis, and requests for patients to “ask their doctor” by providing scripted questions about treatment. Scientific studies showing that patients are being duped don’t stand a chance against this onslaught of misleading information.13 (Of interest, only the United States and New Zealand allow direct-to-consumer advertising of drugs.)
Worse, megavitamins and dietary supplements, apart from marketing budgets approaching $1 billion, aren’t effectively regulated. The FDA fails to counter bogus claims that dietary supplements support joint health or heart health or prostate health or that they boost the immune system or increase energy or reduce stress, because the powerful dietary supplement industry has influenced legislation, effectively tying the FDA’s hands. Again, studies showing that vitamin D doesn’t treat a variety of illnesses can’t possibly compete with a misleading marketing barrage claiming that it does.
To underline the power of medical marketing, a pharmacist at Children’s Hospital of Philadelphia told the following story: “As a pharmacy student thirteen to fourteen years ago, I had a four-week rotation at the VA Hospital in Huntington, West Virginia. I had a woman come into the clinic and, after her blood pressure check, she said, ‘I need to talk to the doctor today, too.’ I asked, ‘What seems to be bothering you?’ In a whispered voice she said, ‘I think I have a “going” problem and would like to talk to the doctor about it.’ She wanted the doctor to prescribe Avodart or Flomax based on the commercials she had seen. These are medications for men with enlarged prostates. I explained to her that her problem wouldn’t be treated the same way [given that she didn’t have a prostate], but she remained unconvinced. She wanted those medicines.”14 Such is the power of drug advertising.
Many physicians practice what they call “defensive medicine.” The concern is that they are more likely to get sued for what they don’t do than for what they do. For example, if a patient receives a heart stent and dies following the procedure, it would be difficult for the patient to sue and win. Surgeries have risks, and people occasionally die following the placement of stents—as is clearly stated on the consent-for-surgery form. However, if the patient is found to have blockage of a major coronary artery and a stent isn’t placed, the doctor might be sued successfully if the patient then suffers a heart attack and dies—even if physical therapy plus medication would have been the better, safer choice.
The solution to this problem is simple: eliminate jury trials. If a patient or family feels that a doctor has engaged in medical malpractice (negligence resulting in harm), then the case should be presented to a commission composed of experts in the field who can most fairly judge whether it really was a case of malpractice. Medical and scientific issues can’t be accurately judged by people without expertise and experience in the subject.
Although the following case takes this problem to its illogical end, it shows just how ridiculous some jury verdicts can be.
In 1986, Judith Haimes, a self-proclaimed psychic, had a headache. She made an appointment to see a neurologist at Temple University in Philadelphia, who ordered a CT scan of her head. The scan was normal. Unfortunately, at least according to Haimes, her psychic powers had now vanished. No longer would she be able to make a living by communicating with the dead. Haimes sued Temple and the neurologist. On March 27, 1986, after deliberating for forty-five minutes, the eight-member jury awarded her $986,000. In order for jury members to have reached this verdict, they would have to have agreed on three separate facts: one, that people have psychic powers to lose; two, that psychic powers can be lost in a CT scan; and three, that the neurologist should have known better than to have ordered a CT scan on a psychic (“What was he thinking?”). Probably the only chance that the defense had to win this case, given the belief systems of the jury, would have been to argue that Haimes should have seen it coming. In August 1986, an appeals court judge overturned the verdict, arguing that it was “so grossly excessive as to shock the court’s sense of justice.”15
Unfortunately, given today’s litigious climate and the influence of the plaintiff’s bar, eliminating nonmedical juries has about as much chance of succeeding as Judith Haimes has of communicating with the dead.
People shouldn’t be expected to be their own doctors, but they should be informed about their health so that at the very least, they can ask good questions. If your doctor prescribes vitamin D or recommends a heart stent or a thyroid screen or a prolonged course of antibiotics, you would do well to know the facts. Then and only then can you be the best advocate for your health and your children’s health. Otherwise, you will continue to fall prey to the inertia, financial influences, and dogma that continue to allow for outmoded, unnecessary, and potentially dangerous therapies.