Industry relationships with editors of pathology journals

I submitted a rapid response letter to an excellent study in the BMJ, which looked at industry payments to journal editors. I provided further data for pathology journal editors.

Pathologists are an indispensable part of patient care and advancing biomedical science. The data show that the pharmaceutical and medical device industries are keenly aware of this. Despite some other specialties receiving a greater amount of industry payments, I hope we do not succumb to glib relativism by downplaying any conflict of interest. Pathologists should self-monitor our profession to ensure these potential financial conflicts do not interfere with clinical practice in matters of test purchasing, selection or interpretation, as well as in scientific endeavors.

You can read my letter at BMJ.com.

Industry payments and pathology

The relationship between physicians and industry has been described as a “closed financial loop.” The type of relationship that most worries me is when a company that produces a drug or a test pays a doctor for consulting or meals or the like, and that doctor simultaneously has a role in prescribing that drug, running that test, or writing related clinical guidelines. Unfortunately, this scenario is common in pathology and throughout medicine.

You can read the rest on STAT.

Hippocrates vs Hypocrisy

Whataboutism can afflict the most well-meaning doctor or the most profit-driven business. With carefully selected examples, the modern medical agenda can always be defended as a resounding success. I’ve heard doctors push back against skepticism with comments like “Well, what about our new cures for hepatitis C?” or “What about our advances in treating pediatric leukemia?” There has indeed been some impressive progress, but systematic examinations of new treatments show only modest success. When we invoke a medical success to shield flawed practices, we create an unrealistic picture of conventional medicine as beyond criticism.

You can read the rest in Undark Magazine.

“fake news” at the checkout aisle

This essay appeared on KevinMD. An earlier version appeared on The Health Care Blog.

I see them every time I wait in the inescapably long lines at the grocery store. They’re offering me so much. Fat-melting foods that “work like gastric bypass.” Sleep masks that prevent breast cancer. One day diets. And, of course, the perennial “medical miracles.” All these revelations can be mine with a simple magazine purchase.

It’s easy to dismiss the medical advice being propagated through the supermarket checkout aisle. Who would take health advice from a magazine sitting next to a box of Snickers and the National Enquirer? This visceral elitism, however, is causing doctors and scientists to miss out on a powerful avenue for improving people’s health. Mainstream health advice was “fake news” before it had a name.

One reason fake health news has remained rampant is because doctors have often refused to engage with the popular press, except for the few seeking profit. When we reject bringing our ideas to the most unpretentious of media outlets, then only mercenaries like Drs. Mehmet Oz and Andrew Weil adorn the covers of these rags. We cannot always stop quackery from being disseminated, but we can drown it out with accurate and nuanced information.

So here’s a challenge for my scientific and medical colleagues: publish your next article in Woman’s World. Or maybe in Family Circle, Good Housekeeping, or Glamour. These magazines, and others like them, have circulations of over 1 million readers. There is a constant hunger in the popular press for health information, yet we are ceding the public conversation to people without the appropriate experience and intentions.

University press offices have started to aggressively “fill the gap” in health news. However, relying only on press offices to promote our work to the public allows these large organizations to prioritize their own success and aggrandizement above the public’s health. Effusive reports about preliminary trials and mouse studies contribute to “fake news” rather than counter it.

Senior professionals already consider it a feather in their cap to write for smart outlets like The New York Times or The Atlantic, but they protest less pompous publications. It is an ineffective gambit to bet that not working with the mass media will solve the health sensationalism problem better than working with them. If doctors think holding our expertise hostage will make the media eventually come to us on our terms, centuries of bad health news should prove that wrong.

This exercise offers us valuable practice in communicating our ideas not just to the people who study them but to the patients and citizens who will be directly affected by them. Everyday people crave medical information and use the convenience of the popular media to receive it. Too many people today still lack the access and financial capacity to receive all the medical care and education they need. Too many health resources target wealthy, educated patients, rather than reaching out to every community that needs this knowledge. There may even be a hint of sexism at our dismissal of “women’s” magazines as an influential medium for the public good. The intelligentsia’s surprise at Teen Vogue’s quality reporting is emblematic of this mild chauvinism.

Since academics, doctors, and other professionals still equate exclusivity with value, I am challenging us to try populism on for size.

I call this a challenge because I recognize it’s not an easy transition from journal to supermarket broadsheet. These magazines frequently promote sensational and unproven health information, and we don’t want our ideas to be similarly stigmatized. We have a situation right out of a game theory textbook: we would all benefit from improving the health information in the popular media, but no one wants to take the risk first. We may be more effective if we take the plunge together.

One barrier is that the style and connections required for mass media publishing are separate from those needed for academic publishing. It can be scary to start from square one. There have been some admirable attempts to help doctors and academics break into this world. The OpEd Project supports academics who want to publish in the mainstream media. The Conversation publishes syndicated articles by academics. For years, Health News Review has been taking the mainstream media to task for poor health reporting. We need all the support we can get as we strive to communicate our ideas in an appealing, clear way.

Let’s start the long process of cultivating relationships with publications that have not had the benefit of input from doctors and scientists with integrity. If you’ve ever laughed at the latest Dr. Oz gimmick, then this challenge is for you. In this era of “fake news,” we can improve the public’s health by asking every doctor and scientist to submit one article or idea to a mainstream publication this year.

As we take on more responsibility, we must also hold the mass media to a higher standard by reaching out to them when health falsehoods are spread. We can have a tremendous impact if we start to think beyond impact factors.

Why calling your pathologist might be a good idea

When I tell people I’m a pathologist, their first comment is usually about autopsies. Most people are only exposed to the field through watching forensic pathologists on television – the people who perform autopsies on murder victims. Admittedly, forensic pathology is the most exciting, cocktail party-ready aspect of our job. But it’s not what most pathologists do.

Most pathologists practice surgical pathology, which is diagnosing disease from tissue removed from your body. Perhaps our most important job is diagnosing cancer. Nearly every cancer diagnosis a patient receives was made by a pathologist, though the news is often delivered by an oncologist or surgeon who has read our report. We are called “the doctor’s doctor” for that reason. Ultimately, however, we are the patient’s doctor, and patients should know that they might benefit from talking to their pathologist.

You can read the rest on Healthy Debate.

Immigration and pathology

My letter in the Los Angeles Times.

To the editor: Your articles have mentioned the effect this ban may have on teaching hospitals and training new physicians.

I am a resident physician at Yale-New Haven Hospital and I train alongside Syrians, Iranians and other immigrants. Let me be clear: They make American healthcare better. America’s finest hospitals rely on the brightest doctors from around the world. In pathology, my field of medicine, more than half of all new residents went to medical school outside the U.S.

This policy is deleterious to American healthcare but also has a human cost. Some of my colleagues have spouses working in other countries. They may no longer be able to see them under this ban. Other immigrant residents fear they too may be the next victims of an executive order.

It pains me to watch my colleagues, as well as my patients, suffer under this anti-immigrant agenda of the White House.

Benjamin Mazer, MD, New Haven, Conn.

Reactionary politics and alternative medicine

Looking back, 2016 could be called the year of reactionary politics. Donald Trump was propelled to the presidency through widespread populism, helped by the fringe, conspiracy-theory laden alt-right community. A reactionary, antiestablishment sentiment prevails. The equally dissatisfied alt-med movement aims to have a similar disruptive effect. It certainly has some high-profile proponents: President-Elect Donald Trump has courted the community by tweeting about vaccines and autism while Jill Stein, the third-party presidential candidate and a physician, has explicitly attempted to merge alternative medicine culture with populist politics.

Alternative medicine is an innocuous, even attractive, term, framed as a healthy, natural option other than conventional medicine. What could possibly be bad about alternatives and nature?

The truth is, there’s little unconventional or natural about the factory production lines and multibillion-dollar industry behind most of the so-called alternative products used by millions of Americans.

Instead, much of alt-med is based on a deep distrust of for-profit medicine and science. Just as the alt-right community reacts broadly against the political establishment, the alt-med community seems more interested in reacting against the corporatization of medicine and nutrition and less about proposing its own reasonable, evidence-based alternatives.

You can read the rest on STAT.

Overdiagnosis awareness month

September was Prostate and Thyroid Cancer Awareness Month, October was Breast Cancer Awareness Month, and November was Lung Cancer Awareness Month. We should designate December as Cancer Overdiagnosis Awareness month, because a lot of cancers diagnosed by screening tests will never kill you.

Through decades of advocacy by patients, family members, and doctors, the public has never been more aware of the dangers of slow-growing, yet sometimes deadly cancers like thyroid, breast, and prostate cancer. Newer, more sensitive tests are promoted to encourage early detection and treatment. These interventions, it is said, “save lives.”

Undoubtedly some lives have been saved by the increased early detection and treatment of symptomless cancers. Yet there is another side: the problem of overdiagnosis. That’s when doctors diagnose a disease that won’t cause the death of a patient during the patient’s lifetime. And it is a complicated problem: Many diagnoses and treatments doctors provide today simultaneously have the ability to be either life-saving or unnecessary but nonetheless life-altering.

You can read the rest at The Boston Globe.

Editorial about gay blood donation

Public policy can have a profound affective role in our society. Law professor and bioethicist Dov Fox refers to this concept as the “expressive dimension” of public policy. He contends that a policy can be discriminatory and harmful if “the policy communicates a social meaning — independent of any bad intent or bad effect — that erodes worthy forms of public recognition.” Banning a stigmatized group from participating in the social good of blood donation, independent of any rational merits of the policy, signals to the public a sense of that group’s social undesirability.

An honest, ethical evaluation of our blood donation policy must acknowledge that gay men are far more likely to live with fears of HIV, violence, and ostracism than straight people. Instead of valuing the outsized fear that straight people have of homosexuals, we could instead reintegrate gay men into charitable society through a science-based blood donation policy.

You can read the rest on STAT.

Hippocratic capture: Thoughts on the undisciplined physician

This post originally appeared on KevinMD under the title “What is the proper way for physicians to be leaders?”.

In medical school you learn very quickly that you can’t know everything. By the end of your first-year anatomy course, you’ll probably give up on learning the names of every part of the body, let alone the intricacies of how they function. As physicians, we must grow comfortable with our limitations. We seek help from our colleagues and try not to let our egos get in the way of patient care. We accept that no physician will ever master the entirety of his or her discipline.

But are physicians now expected to master other disciplines, such as software engineering and social work? If you read the popular press and even academic journals you may think so. I like to call this phenomenon, this growing body of subjects doctors “should” master, Hippocratic Capture.

I was reminded of this new pressure most recently while reading this article in a New York Times blog. The author makes some excellent points. Medical curricula are relatively stagnant while our world rapidly changes. The best medicine will incorporate modern technology and respect for the socioeconomic factors that influence patients’ health. The author also complains that he sometimes feels as if he has only one tool in his toolbox — the biomedical framework. For many health problems, this feels like simply not enough.

It’s hard to imagine any physician not empathizing with this struggle. But is the solution for medical students to take design courses from a Fine Arts school, as the new Dell Medical School is planning (according to the NY Times blog)? Should doctors also become designers?

Doctors face the paradox of being among the most visible and respected members of the healthcare field. While this authority provides many rewards, it also places an enormous expectation on us as leaders of healthcare. Doctors are expected to heal the sick (and we want to). If socioeconomic struggles are leading to sickness, doctors are expected to fix that. If technology provides the opportunity to democratize healthcare, then doctors are expected to lead the charge. We’re even supposed to design better hospital gowns, at least according to Dell Medical School’s example of its innovative new curriculum.

But to point out the obvious: we can’t do it all! Doctors have already come to terms with our inability to master the entirety of biomedical knowledge, and we need to come to terms with our inability to personally fix every social determinant of health or poorly-designed health system. In fact, we can better provide these influencers of health the respect they deserve by allowing the true experts to take charge.

There are millions of social workers, public health professionals, software engineers, designers, and others who have the ability and desire to improve people’s health through their respective disciplines. The solution isn’t for physicians to master yet another subject, it’s to build powerful interdisciplinary teams that can address these aspects of healthcare in an egalitarian manner by including many kinds of experts. Doctors and other providers can no longer be the only ones responsible to the public for creating the best possible healthcare system. This physician-dominant model is regressive and inefficient.

I am not suggesting that doctors should ignore problems outside of the biomedical framework. I personally attended business school in addition to medical school because I was excited by the opportunity to improve patients’ health through innovative healthcare delivery. But I went to business school precisely because I didn’t expect the intricacies of management and economics to be taught in medical school. I don’t expect all physicians to master this part of medicine.

I am suggesting that if doctors are expected to master the multitudinous disciplines that are relevant to health, then eventually the biomedical aspect of medicine will suffer. After all, despite the need to address the social determinants of health, you still need someone who knows how to take out an appendix. In forward-thinking health circles, the “biomedical framework” has become an epithet. It represents the myopia of past physicians, who thought scientists in a lab would cure every disease, ignoring issues of poverty, education, and behavior. But biomedicine is still a vital part of good care delivery and should remain at the center of medical education.

While many types of professionals can address healthcare policy, good design, and innovative technology, only physicians have the duty to provide medical care under the biomedical framework. When someone requires a surgery or drug for their illness, it is doctors who are responsible for ensuring the proper selection and delivery of that type of care. We can dilute our education, but we cannot dilute that responsibility.

Doctors should have some familiarity with the many disciplines that affect health. This isn’t a new idea despite what the popular press would lead you to believe. I attended the University of Rochester’s medical school, which since the 1970’s has been home to the “biopsychosocial model” of medicine. I greatly value the broad experiences I received from learning under this medical model. Even in this environment, however, I spent plenty of time learning the pathophysiology and technical skills that are traditional parts of medical education.

I personally look forward to addressing the business side of healthcare in addition to providing good medical care under the biomedical framework. When I do work on issues outside of this framework, however, I expect to succeed not by knowing everything there is to know about healthcare delivery, but by engaging administrators, engineers, and others through interdisciplinary teamwork. If physicians are expected to be leaders of the healthcare system, then this is the proper way to lead. Hippocrates, after all, didn’t need an MBA or MSW to be a good doctor.