Medical epistemology

As I learn more pathology, I see the uncertainties inherent in medicine’s definitions. Cancer is not merely cancer but a product of philosophy, linguistics, and probability. I have been surprised to learn how much the undergraduate medical curriculum downplays the importance of epistemology on disease screening, overdiagnosis, and overtreatment. As a medical student, talk about these topics was theoretical physics—impossible to connect to real practice. As a pathologist, my definition of disease has become an atomic bomb leading directly to patient care and well-being.

You can read the rest in Academic Medicine.

Media ethics guidelines

The AMA report describes the diverse and sometimes conflicting roles that physicians have in the media. When a doctor is treating a patient, for example, our duty is clear: above all else, we must act in the patient’s best interest. In the media, however, a doctor’s role may not always be so clear: she may be reporting on basic health information, interpreting a new scientific study, advocating for a specific intervention, or representing a commercial organization. Patients who are used to doctors only playing one role may be confused by these competing priorities.

When the goal is to entertain and even profit from a media appearance, a doctor’s priorities may dangerously shift away from the patient.

You can read the rest on Health News Review.

What can brutalist architecture teach doctors?

The current fashion in medicine is to label things as either “evidence based” or “not evidence based.” We use these labels to describe treatments, diagnostic tests, public health policies, and even people. This dichotomous worldview, however, fails to capture the nuance of the medical landscape. The use of evidence to drive medical decision making should be lauded, but there will always be more to providing proper healthcare than reading statistics in a journal or following clinical algorithms. The shorthand we use to convey this reality is “the art of medicine.” I think a better analogy would be “the architecture of medicine.” After all, proper medical care has a structure built around a clear purpose: to improve the health of the patient. It is engineering with flair.

At the same time, an unyielding focus on utility and regulatory compliance is the cause of many of contemporary medicine’s vivid eyesores: the proliferation of rigid yet contradictory clinical guidelines; blunt point-of-care applications; and electronic medical record systems usually described as a hurdle rather than as a tool. Each of these engineering innovations promised medicine a new evidence based foundation but have instead been introduced without considering the longstanding traditions our community holds dear. This contradiction in today’s medical practice, its simultaneous focus and myopia, is reminiscent of the brutalist architecture movement.

You can read the rest in The BMJ.

Should we demand everyone get screened for cancer?

The American Cancer Society, biomedical giant Genentech and the governors of states including Texas, Pennsylvania and Florida have all declared December 4 through 8, 2017 “Cancer Screen Week.” This initiative has noble intentions: to catch cancer at its earliest stages and prevent unnecessary death. Who could have a problem with such a goal?

The problem is that while some individuals will have their lives saved by early cancer detection, if every person were to undergo screening, there would likely be no lives saved overall. It’s counterintuitive — but it’s what the evidence says.

You wouldn’t know this from the Cancer Screen Week promotions. The Cancer Screen Week website does not mention the risks and limitations of screening — only benefits. It declares simply, “Get screened now.” It asks patients to sign a “screening pledge card” as if this were a public television fundraiser and not an intimate medical decision that could result in life-altering surgery, chemotherapy or even death.

You can read the rest on WBUR.

Pathology’s other sense

Marcel Proust was hardly the only person to note the uniquely evocative coupling that smell has to memory. In medical school, we are reminded that olfaction is the only sense whose neural connections communicate directly with the memory centers of our brain. In the course of a day, my specialty’s smells take me close to death yet back to childhood. At times, the deafening exhaust systems and blinding light of the microscope isolate me from our human task, but when the molecules creep into my olfactory neurons, this job’s intimacy with human bodies — and human beings — could never feel closer.

You can read the rest in the Journal of General Internal Medicine.

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

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. (Please cite KevinMD version.)

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.