A flyer appeared in my mailbox the other day advertising a surgical technique for a particular hospital system. I’ll refrain from specifics. The advertisement, however, wasn’t unlike a lot of health-related advertisements. In this case the advertisement claimed, “less pain, “shorter hospital stay,” and “faster return to your regular activities” with this new surgical technique. When confronted with this sort of claim, the savvy health consumer should ask, “compared to what?”
Health care is expensive and fee for service still keeps the lights on for most hospitals. Getting folks in the door is the first step in getting those fees rolling. I hate to sound like medicine is just another business but in some ways it is. It would be naïve to think advertisements by health systems are motivated exclusively by some sense that coming to one health system over another is in your best interests. That would be altruism and there are some who legitimately feel this way about advertising health services. In some cases they are right (e.g. going to one hospital is better than going to another) but in many/most ways the consumer of health services needs to embrace the adage, “let the buyer beware.”
Most of medicine is practiced without substantial proof that it works. Indeed according to the now defunct Office of Technology Assessment (OTA), fewer than 30% of procedures currently used in conventional medicine have been rigorously tested. Since the OTA was retired in 1995, and given the introduction of new procedures and technologies have likely exceeded credible investigations as to their clinical merit, that 30% number is likely vastly underestimated. This is certainly true for the surgical tool marketed in my advertisement mailer. Indeed credible investigations comparing this surgical approach with other convention approaches do not fully support the claims made. Even more poignant is the innovation was being promoted for a procedure one study estimated was done without good cause in 70% of cases. Ouch!
To be sure physicians and by extension the health systems they represent, want to do well for their patients. At least part of the problem is that much of medicine doesn’t understand what constitute “proof” of effectiveness. For example, one study found sixty-percent of gynecologists asked to estimate a woman’s chance of having breast cancer following a positive screening mammogram overstated the risk. Statistics, that branch of mathematics that is often central to judging the comparisons made in clinical studies, can be really confusing and acquiring and maintaining a working knowledge of this is difficult for most clinicians. To make matters worse, industry influence and just plain bad study methods, has made identifying credible investigations almost like looking for a lost needle on the hospital operating room floor…or haystack.
So what are you suppose to do? Here are some helpful rules of thumb about consuming medicine:
1) Carefully weigh any recommended therapy with what you find important seeking to understand what evidence exists regarding how the therapy works for addressing what you find important.
2) Take advantage of a medical librarian. Many hospitals have medical librarians who can help you find studies relevant to your problem. See what they can find. You can “Google” your problem but sometimes that just brings up junk. A medical librarian can help sift some of the junk out.
3) Don’t be afraid to ask your physician hard questions about what proof justifies the treatment recommendation. If they appear offended check out the next rule of thumb.
4) Get a second opinion…maybe a third?
5) Understand the bias. Bias occurs anytime there are hidden influences that push opinions in a specific direction. Bias can be good or bad but you’d like to minimize bias in medical studies or in treatment recommendations. One problem folks have with industry buying physician lunches is the problem of bias. On September 30, 2014, as part of the Sunshine Act, the federal government will release most of the data showing how much money industry gave to physicians. In pursuit of understanding the bias, that data might be helpful to look over when it becomes available.
6) Seek a consultation with a physician who publishes research. If a physician conducts and publishes research then there is a better chance they are better at interpreting the current literature on a topic. Note I just said “better.”
7) If waiting is clinically appropriate, resist the temptation to decide on any aggressive therapy the day you are offered it.
My list isn’t perfect. There are always going to be gaps between what you and your clinician know about a given medical problem. That gap is safeguarded historically by a privileged ethical relationship wherein the patient’s interests are to be given priority over those of the clinician or the health system. There are lots of good and bad reasons why understanding what’s best is not such an easy task. Facing that challenge, when presented medical facts regarding a treatment being offered to you don’t forget to ask, “compared to what?”
James L. Whiteside, MD, MA 