No Matter the Medium, The Health Care Messages You Must Get Right

Gary SchwitzerPublisher, HealthNewsReview.org

Our criteria: Does the story explain…

What’s the total cost? How often do benefits occur? How often do harms occur? How strong is the evidence? Is the condition exaggerated? Is this really a new approach? Is it available? Are there alternative choices? Who’s promoting this? Do they have a financial conflict of interest?

After 5 years and 1,500 stories

72% fail to adequately discuss costs. 68% fail to quantify benefit - often how

small is potential benefit66% fail to quantify harm - often how

large is potential harm65% fail to evaluate the quality of the

evidence58% fail to compare new idea with

existing options

Kid-in-candy-store picture of U.S. health care

Everything is terrificNothing is riskyNo price tags

Daily drumbeat of news Steady diet of news from journals - disregard

for publication bias for positive findingsAdvertisingWeb health infoInfo from conflicted patient advocacy groupsNews releases from industry, academic medical

centers, even from journalsMisleading Twitter messages

Concerns about cumulative effect of health messages

Actual newspaper headlines on DaVinci Robot Surgery

Robot doctor - surgery of tomorrow Da Vinci puts magical touch on the prostate Cancer survivors meet lifesaving surgical robot Robotic surgeon's hands never tremble Da Vinci is code for faster recovery Robot is surgery work of art Hospital hopes robot surgery will lure patientsWHAT’S THE HARM OF THIS?

What’s the harm?

British Journal of Urology – June – found “massive media coverage” of robotic prostatectomy “a major contributor” to rise in consumer interest in it.

Journal for Healthcare Quality – May – found hospital websites hype robotics, ignore harms, are influenced by manufacturers. Author: “"This is a really scary trend. We're

allowing industry to speak on behalf of hospitals and make unsubstantiated claims….violation of public trust.”

“Robotics blamed for spike in prostate surgery.”

• American urology conference last month

“There is other evidence to suggest that radiation therapy use also is increasing, largely in the form of intensity modulated RT. I think there is pretty good evidence that the pie is getting larger. Why is that, in an era when the incidence is going down and there is no reason to believe that the disease is a lot more dangerous than it used to be?”

James Montie, MDUrologist

University of Michigan

June: Tufts study funded by AHRQ

Review of the available literature on radiation and prostate cancer, including 10 randomized controlled trials and 65 observational studies.

They concluded there was "insufficient evidence" to say with certainty whether radiation treatment compared to watchful waiting is more likely to save lives.

Yet expensive new technologies like proton beam therapy and intensity-modulated radiation therapy are proliferating.

What’s the harm?

Stories whip the“worried well” into a frenzyRaise unrealistic expectations of health care systemPromote undue demand of costly, unproven

technologies that may produce more harm than good.

Communication of these issues - itself - is a major health policy issue.

News coverage & poor public discussion of screening tests should be most concerning.

Worst, most biased coverage I’ve seen in 35 years

10 claims that many stories didn’t challenge1. This is all about saving money.

2. This is about rationing.

3. It’s the first sign of Obamacare.

4. Government is deciding some lives don’t matter.

5. Early detection always saves lives.

6. The fact that I or someone I know was saved by a mammogram proves that more testing is better.

7. The shifting recommendations prove that scientists are clueless.

8. This was surprising and came out of nowhere.

9. The task force members must be uninformed idiots - especially since none was an oncologist.

10. American Cancer Society disagrees so the task force must be wrong.

The Public's Response to the U.S. Preventive Services Task Force's 2009 Recommendations on Mammography Screening

"Of the 233 newspaper articles, blog posts, and tweets coded, 52% were unsupportive, and only 18% were supportive....These results are consistent with previous studies that suggest a media bias in favor of mammography screening."

May Harris Poll• 11 percent said they believe mammograms should start in the 20s, even for women with no risk factors, while 29 percent believe mammograms should start in their 30s.• 45 percent of the women polled said the task force pushed back the recommended age to 50 to reduce health-care costs and avoid administering unnecessary tests.

As 37-year ChiTrib & NYT vet John Crewdson wrote in The Atlantic…

“There are multiple reasons women are ill-informed about breast cancer. The fault lies primarily with their physicians, the cancer establishment, and the news media--especially the news media. Until coverage of breast cancer rises above the level of scary warnings mixed with heartwarming stories of cancer survivors, women are likely to go on being perplexed."

Other examples: Chicago Sun-Times Wall Street Journal Washington Post New York Daily News Minneapolis Star Tribune All TV networks

The ink isn’t even

dry on studies before

marketing begins

On Twitter last week

Men’s Health magazineIf you're a smoker, you NEED to get a CT scan. Body of story: “But don't run out and ask for one.” (cost & false positives)

AARPAre you a smoker? CT scan those lungs Body of story: 371 words of caveats.

HealthDay wire service didn’t challenge researcher promoting universal pancreatic cancer screening for everyone over 50.

After study of tissue from 7 people!

Screening Madness

Crusading one-sided advocacy

“I honestly believe it is better to know nothing that to know what ain’t so.”  

Josh Billings (pen name of humorist Henry Wheeler Shaw, 1818 – 1885)

Crusaders just KNOW that screening makes sense. And they easily whip into a frenzy the “worried well” public.

But what they know often just ain’t so.

Why don’t we deliver this message?

“All screening tests cause harm;

some may do good.”

But much health journalism consistently emphasizes benefits & minimizes harms

And that’s the message I think we’re missing

That there’s a harm behind non-evidence-based promotions

That there’s a harm in selling sickness…in selling the search for weapons of mass destruction inside all of us

Communication of the evidence about tradeoffs – about harms - is a key health policy issue

Health Affairs paper: “Evidence That Consumers Are Skeptical About Evidence-Based Health Care.” “The beliefs that surfaced in both the qualitative research and the survey—more is better, newer is better, you get what you pay for, guidelines limit my doctor’s ability to provide me with the care I need and deserve—are deeply rooted and widespread.”

Carman KL, et al. Health Affairs 29, No.7 (2010)

Even in 300 words journalists can explain

that… More is not always better Newer is not always better Screening doesn’t always make sense.

Journalists could help consumers be smarter, healthier skeptics

Or we could & actually do cause harm.

Summary of weaknesses

Failure to quantify harms, benefits, costs Failure to evaluate the evidence

Biggest subset = conflating association with causation Reporting only the benefits of screening tests

without considering the considerable harms Terrible sourcing

Failure to get independent perspectives Ruining balance with “tyranny of the anecdote” Glowingly positive patient stories not balanced by

treatment failures, dropouts, dissatisfied, or “watchful waiters”

Journalists’ pushback

Journalists who won’t include harms, absolute risk/benefit data, NNT, even conflicts of interest if researchers don’t provide that info;

Bloggers complain that they are being reviewed as if they are complete news reports;

Some say “Don’t fault a journalist for reporting presentations highlighted at conferences. It’s a competitive world. Fault the meeting organizers for highlighting marginal reports.”

“Schwitzer’s alarming report card of the trouble with medical news stories is thus a wake-up call for all of us involved in disseminating health research—researchers, academic institutions, journal editors, reporters, and media organizations—to work collaboratively to improve the standards of health reporting.”

A telling rejection letter from another journal:

“While we applauded the standards (used by HealthNewsReview.org), some of us wondered if it was realistic to expect that most physicians and scientist-authors, let alone journalists, could realistically meet those standards given the generally poor training all receive in the systematic review and interpretation of evidence, and the presentation of that evidence and its contexts in written form.”

Another journal rejection: “Many of your examples don’t seem all that bad.”

A Saint Paul Pioneer Press story promoted hospital “Mingle & Mammogram” parties for women starting in their 40s without exploring the evidence for why the U.S. Preventive Services Task Force expressed concerns about mammograms in that age group.

A Prevention magazine special report - “7 Tests You’re Not Having That Could Save Your Life” – promoted several cardiovascular screening tests without any evaluation of the evidence and told the stories of 3 women with heart attacks in their 40s and, for each, listed the “screenings she should’ve had.”

A New York Times story reported that a spinal fluid test could be a “100% accurate” screen as an early warning on Alzheimer’s disease.

”We are going to relentlessly chase perfection, knowing full well we will not catch it, because perfection is not attainable. But we’re going to relentlessly chase it, because in the process we will catch excellence. I’m not remotely interested in being just good.” Vince Lombardi, in his first meeting with his Green Bay Packer players in 1959

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