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Thursday, May 1, 2014

The gravity of misinformation

The recent concentration of misleading media hooey about health has been excruciating, but the problem is perennial. I trust I needn’t make the case that you are under constant assault by distorted, contorted, titillating, and insipid headlines. This is certainly true in my domain of health and medicine; it may well be true more generally, but I tend to limit my commentary to the realm of my actual expertise. But to whatever extent the problem is universal, I am hopeful the remedies may be as well.

Pick almost any topic you like. The obesity epidemic is over; the obesity epidemic is worse than ever. Childhood obesity rates are plummeting; childhood obesity rates are stable if not rising. Saturated fat is good for us, not so bad for us, or worse for us than cigarettes. Fish oil causes prostate cancer, except that it doesn’t. Nutrient supplements are all useless, except for the ones that are useful. Vaccines cause autism, except they don’t, and not getting them leads to measles outbreaks.

While topics generally related to nutrition tend to occupy much of my time and effort, the story of hormone replacement at menopause has particular relevance to this tale. We once thought that so-called hormone replacement therapy would substantially reduce the chronic disease burden in post-menopausal women. Then, when randomized trials suggested that wasn’t so, we wound up with such hyperbolic headlines that women and their doctors tended to flee in panic from discussion of the topic. Use of hormone replacement plummeted, even for those women likely to benefit and even from those forms of hormone replacement never tarnished with negative findings in the first place. A detailed analysis colleagues and I conducted and published in the American Journal of Public Health suggests that this most recent round of distortions has resulted in the premature deaths of as many as 90,000 women over the past decade; women who would have benefited from the right form of hormone replacement but were too horrified of the topic even to consider it.

This goes beyond tossing out baby with bathwater, which is bad enough. This is mass casualty mayhem. Media distortions in the realm of health and medicine come with potentially serious consequences.

Clearly, then, for those of us not wanting to figure among the victims of this prevailing mischief, there is a need for self-defense. When it comes to media martial arts, I prefer judo to karate.

I say that as a long-time student of tae kwon do. With all forms of karate, your adversary charges at you; you charge back in defiance. Limbs are let fly. Generally, there is blood on the floor before it’s all over—theirs, yours, or everybody’s.

In the case of headlines, as bad as they often are, you can’t confront them this way or you’ll never get to the potentially useful details. So I recommend “stupid headline judo.” Judo does not oppose force; it redirects it to better ends. That suits the stupid headline scenario perfectly, where there is no direct frontal assault, just hazardous misdirection.

Before elaborating the relevant elements of judo, it’s hard to resist the obvious question: who’s to blame for this mess? It’s all the usual suspects, and one a bit unusual.

First, of course, we must meet this enemy and concede that it is once again us in our gullible multitudes. If we actually preferred illumination over titillation and directed our attention accordingly, hyperbolic headlines would go extinct. They would elicit a roll of the eyes from a population prone to common application of common sense. Would that it were us! It’s not, so let’s move on.

Second, there is the news media, for whom the means of propagating high ratings and large audiences are a poorly kept secret: comfort the afflicted, afflict the comfortable. So, if last week’s headlines provided comfort (or vice versa), this week’s will reliably provide the antidote, however the story has to be torqued to make it so.

Third, of course, there are the advertisers with stuff to sell whose revenue keeps it all spinning. They’ve got skin in the game, and will do whatever it takes to get under ours. Perpetual confusion is just collateral damage on the way to a stock split.

But ultimately, I pin it all on the 1 less usual suspect: Sir Isaac Newton. Newton encumbered us all with those pesky laws of thermodynamics, including this one: for every action, there is an equal and opposite reaction.

That’s the problem, right there. It’s not a measured and sensible reaction; it’s equal and opposite. So if last week’s news was that vaccines eradicated smallpox, this week’s news has to be that they cause autism. It’s not true; it’s just equal and opposite. And the comfortable are accordingly afflicted, and the universe remains in balance.

If last week saturated fat was killing us, this week we can’t simply say “we’re not so sure.” That’s not equal and opposite! This week we need to say: Shmear saturated fat all over yourself and you’ll live forever! You get the idea.

Whatever Sir Isaac’s good intentions, it does indeed seem that every hyperbolic headline generates a hyperbolic headline in the opposite direction at the first good opportunity. We are thus consigned to a universe where misinformation has massive momentum, nonsense begets nonsense, disillusionment prevails, and want of conviction forestalls the translation of knowledge into power.

Let’s fix this. We can’t defy the laws of thermodynamics, but they were never meant to govern our news. We can redirect these forces to more constructive ends.

I) Read headlines only to know that there is (or may be) news, not to know what the news is.
1. Headlines are designed to titillate, not educate
2. If you only read headlines, just about everything you think you know will be wrong

II) Remember there were equally credible (or incredible) headlines last week, saying the opposite
1. Just because today’s news is tomorrow’s fish wrapper doesn’t make yesterday’s opposing headlines any less reliable than today’s
2. Today’s headlines will be fish wrappers tomorrow, when new headlines come along again to refute them

III) Consider that science is incremental
1. Understanding comes with an accumulation of knowledge over time
2. The weight of evidence slowly and inexorably tilts toward truth; that is not so for any single source or study

IV) Look for patterns
1. If there is important news about a medical advance, it will become a theme in both the scientific literature and the popular media
2. If what sounded important at first does not develop into a theme, there was nothing there in the first place but misplaced optimism (or pessimism), a statistical fluke, or artful spin

V) Take it to bedrock
1. It’s bad enough when a distorted headline refers directly to a study, but in this cyberspatial age, often a blog just refers back to another blog, which in turn refers to another blog
2. At best, this cascade creates an echo chamber effect, making it seem as if multiple independent assessments support the same conclusion, when in fact each is merely a repetition of another
3. At worst, this is like that famous game of “telephone” where each repetition introduces more distortion, until by the end, the message is entirely unintelligible
4. So if the subject truly matters to you and has any potential to influence what you do, reach no conclusions until you are sure you got to bedrock, and read an assessment by someone you trust who actually reviewed the study/finding/report on which they are opining

In deference to Sir Isaac, it’s tempting to express all of this as a mathematical formula. But since what I came up with started looking too much like calculus, I’ll spare you.

We can stick with the simple expediency of judo. We can defend ourselves against the forces of silliness that confront us, and no bleeding is required. We really just need to be measured and sensible as opposed to reactionary, adept at bending information toward truth, and committed to standing our ground. Gravity should help.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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