If you hear a health claim sounds too good to be true..

We all have things we believe without evidence. We particularly have things we believe without good evidence. I am not even talking about religious beliefs, which are, by definition, acts of faith, but what we can call lay beliefs about the world. One area in which this is both important and widely variable is health and medicine. There is a tremendous amount of information out there, and much of it is correct, and much is not, and sometimes some correct stuff seems, on the surface, to contradict other correct stuff. If that is true, what is a person to do?

One option is to learn about things in detail, understand the scientific method, understand statistics, and understand how “truth” evolves and changes with new discoveries. Or, alternatively, to know that there are people who do know and understand these things, who have spent years and decades learning about them, being trained in the subtleties of science and research, and listen to what they say. For decades, say roughly from WWII, this is how our public health developed. We didn’t just trust scientists, we trusted science. We could see the progression of scientific knowledge, and how it positively impacted ourselves, our communities, and our nation and world.

You don’t have to be a statistician and understand all the intricacies to understand, for example, the basics of probability. When something is more likely than something else, that doesn’t mean it will always happen. When you throw a pair of dice, it is more likely to come up 7 than any other single number (6 of the 36 possibilities – 1 in 6 -- are 7). This does not mean it will always be 7, or usually be 7, or even be 7 a majority of the time, but (given enough throws) it will be 7 more often than any other number. If you understand this, you are on your way to interpreting scientific data. If you don’t, don’t shoot craps.

In medicine, a diagnostic test or treatment that works only 1/6 times is not likely to be used, so the probability that it will give an accurate diagnosis or a successful treatment is going to be much higher. But almost never 100%. 99% is very good; 1% is a small chance, and if you had a 1% chance of getting 7 and crapping out, or getting a wrong answer on a test, you’d go for it. But if something is done a million times, 1% is 10,000. You, or a loved one, could be one of the 10,000 in whom a test is inaccurate, a treatment fails, or even a side effect kills you. That is terrible for you, but doesn’t increase the likelihood of it happening to the next person. If you throw dice, the odds of a certain combination are the same every single time. Even if someone, say, rolls 11 six times in a row it doesn’t change the probability (1/36) of getting an 11 the next time. There is no such thing as “hot dice” or a “hot shooter”. If you don’t understand that, don’t play craps.

Enough of probability now. The main point is that because something bad sometimes happens with a test or treatment doesn’t make it bad. Some of the issues in health that are most controversial now, like vaccines, are phenomenally and overwhelmingly good. Most of the bad things attributed to it are completely made up (not that the bad thing happened to someone, but that it was the result of the vaccine), and the others are very rare, far more rare than the bad things happening to the unvaccinated.

While truth does evolve and change with new discoveries, those changes are usually logical and stepwise. We know about something, and new information increases our knowledge. It rarely completely contradicts everything we know; it theoretically could and there have been some discoveries that did, but if a claim seems to it is very unlikely. It is usually internet spam, promulgated by people who think you are a sucker and may pay them for something that magically solves a problem. If you have a health problem, this is almost never the way to go. Sure, pharmaceutical companies are scum-sucking parasites who would kill their mothers, not to mention you, to make a buck, but that doesn’t mean the medications that they make are bad, ineffective, or more dangerous than what you can buy over the internet because somebody says it works. The FDA (at least historically, before it became decimated) required rigorous testing of medications before they are released to the public, while the miracle cures you see on the internet have not. In addition, the doses are standardized and consistent. You can know what you are getting, and if you cut the dose in half or double it, that is what you are doing. With unregulated drugs, you don’t know.

Yes, there are many natural substances that can help, and indeed many prescription and regulated drugs have their origin in them. But even though aspirin may have originated from willow bark, how much willow bark is the right dose for you? From what age tree? Growing in what conditions? In what season? What about next time? Or your next door neighbor? Or your kids? A good rule of thumb is the old saying: If something seems too good to be true, it probably is. “Magical” cures on the internet never are. Another old saying, attributed to P.T. Barnum, is “a sucker is born every minute”. No one wants to be that sucker, but people are remarkably inconsistent about when they will be judicious and when they will swallow the Kool-Aid whole.

If someone you hate and think is stupid tells you something that sounds ridiculous and unbelievable, you probably won’t believe them. But what if it is a friend? If what they say is something that you already think might be true? Looking things up on the internet (sometimes called “doing your research”) is actually not a bad way to start. You usually find accurate information. This is really different from reading something sent to you or spammed out by bloggers (like me) or “influencers”; if someone is “reaching out” to you, it is basically marketing. Think of the difference between you calling your bank to find something out about your account and getting a call from someone that says that they are your bank!

How does this relate to social justice? Are there not believers and non-believers in data and science in both majority and minority groups, among the young and old, among the rich and the poor, among liberals and conservatives? Sure, but the impact is different among these different groups. Many people are not only acting on their own fringe and unscientific views, but pushing and promulgating them to others. And, as always and as in almost everything, it is the poorest, least empowered, least educated, most marginalized, those with the thinnest safety net, who suffer the most. We may occasionally read of someone who has been hoist on their own petard, refused vaccination and died of the disease, followed a wacko diet or taken unregulated medication who gets ill or dies from it, but when the society or government rejects science in favor of public health policies based on fringe beliefs, it is the least well off who are most often harmed.

Remember, there may be magic in the movies, but there is not real magic in the world. If something sounds to good to be true…

"Uncomplicated" Primary Care?

.
I have often written about the importance of primary care, the shortage of primary care physicians, and the fact that fewer medical students are choosing primary care careers, which will exacerbate the problem. A key part of this analysis is the large number of studies, by researchers from a variety of settings, that show that the presence of a higher proportion of primary care doctors decreases cost and increases quality.[1],[2],[3],[4],[5] Indeed, there are studies that show that health disparities in infant mortality and low birthweight can be virtually eliminated by a greater presence of primary care.[6]

However, not everybody agrees. In an earlier post, More Primary Care Doctors or Just More Doctors?, I discussed the position taken by Dr. Richard Cooper, former Executive Vice President and Dean of the Medical College of Wisconsin and currently Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, who argues against this position, as well as rebuttals from some of those he has criticized. In a recent publication supported by the Physician’s Foundation, a group comprised primarily of state and local medical societies, “Physicians and their practices under health care reform: a report to the president and the congress”, Dr. Cooper and a group of equally distinguished colleagues restate this position; in particular that the value of primary care is overstated. In an excerpt from the Executive Summary they note:

"Primary care has been a central focus of health care reform. In modeling the future workforce, the Project Team acknowledged the critical importance of primary care services and the role of generalist physicians in providing them. However, the Team rejected the claim by Starfield and others of lower mortality in regions with more family practitioners as a statistical anomaly, and it questioned the wisdom of deploying generalist physicians to take responsibility for the proposed medical homes. Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care"

This is quite a strong statement in opposition to what I, and many others, have been saying in support of the importance of primary care to the health of the public, so of course one looks for the supporting data, especially for the striking dismissal of the work of Starfield and others as “a statistical anomaly”; however the data isn’t there. Presumably, when people are so distinguished and feel their positions so strongly, such data is unnecessary. One distinguished colleague put forward this definition:

Statistical anomaly: A consistent finding, in multiple nations and health systems that disagrees with my current self-interest and bias.

That says it very well. If you have no data to justify publication in peer-reviewed journals, you can continue to perpetrate your ideas in foundation-sponsored opinion pieces.

Several organizations, including the American Academy of Family Physicians (AAFP) and the Association of Departments of Family Medicine (ADFM) have protested this publication to the sponsors, the Physicians Foundation. The Foundation took the position that it commissioned the study but did not endorse it; that it was supportive of primary care, and chose to focus on other findings of the report (such as that socioeconomic differences make a difference in geographic variation, which the Dartmouth Atlas researchers are purported to have ignored in their analysis). The PF states its unequivocal support of primary care in a letter to the President of ADFM: “As for the Physicians Foundation (PF), it would never do anything to damage primary care.” Nonetheless, the AAFP found this inadequate; its formal response to the PF includes the following:

“This report is an attack on decades of sophisticated research that validly supports the value and need for improving access to robust primary care using a thin vein of research that has been publicly demonstrated to be oversimplified and wrong. The authors’ perspectives and opinions are welcome in the debate about how to reform the health system and physician workforce, but this report is largely opinion richly dressed in discredited, unsophisticated research.

This study is largely a recapitulation of the primary author’s paper in Health Affairs in January of this year[7]. In that same issue, several researchers pointed out the fundamental flaws in this simplistic research showing that important basic adjustments showed this work to strongly support the prior studies it criticized. It continues to claim that population differences explain past findings for the value of primary care and variance in spending, when these were fully accounted for in these studies. This report does not repair those flaws. It labels several well-validated and valued studies as “anomalous” and “simple frameworks” without supporting evidence from other sources. We feel that such claims carry an obligation to point out specific errors of methodology or data, not just recapitulation of personal belief. The burden of proof is still overwhelmingly against the evidence upon which this reports rests. Its foundation is flimsy.”

Enough said about the lack of intellectual rigor, and essentially incorrectness about this piece. More important, I believe, the other assertion in the quote from Cooper’s paper, above, neatly packaged in the sentence “Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care". What is this “uncomplicated primary care” of which you speak? The idea that provision of primary care is simple, unchallenging intellectually, not worthy of the training of a physician, and could be done by someone with much less training, is a position put forward by other specialists and subspecialists that is:

· Common, especially in speaking to medical students,
· Derogatory, and offensive,
· Self-serving, since obviously the services provided by the subspecialists are much more rigorous and difficult, and
· Wrong.

The myth is that primary care is about patients with colds and high blood pressure checks. The reality is that it is about people with multiple chronic diseases who need management of those conditions as well as coordination with whatever other specialists they are seeing; preventive services delivered; counseling and “asking for trouble” (“are you safe at home?”); discussion of whatever the other specialist may have recommended; and, of course, caring for acute complaints. This is hard, complex, time consuming and difficult. Yarnall, et. al, in the American Journal of Public Health, identified that it would take 7.4 hours a day for a primary care physician to just provide the preventive services, not to mention all the other services above, especially chronic disease management.[8] One of my residents recently returned from a rotation on cardiology; on her first day she was sent to see a patient and returned in 7 minutes. “That was fast,” said the cardiologist. “You just wanted me to address their heart problem,” the resident, used to caring for many different problems in a family medicine visit, replied. Perhaps this is cognitive dissonance for the subspecialist (or “partialist”), who has to believe that their in-depth knowledge of one particular set of conditions is at a higher level than managing the whole person with all of their complex medical, psychological, and social and economic issues.

Another wise colleague, who believes that “The question of what is intellectually challenging and worthy of training and intellect is a classic example of hubris perpetuated by subspecialists and academic health centers,” asks the following question of his medical students:

“What is more intellectually challenging?
Performing your 2000th knee arthroscopy
Performing your 3000th laparascopic cholestectomy
Performing your 4000th bronchoscopy
Performing your 5000th colonoscopy
Performing your 6000th intubation
Performing your 7000th breast augmentation
Performing your 8000th cataract removal
Reading your 10000th MRI
Seeing you 15000th case of acne (achievable in 7 years seeing 10 case a day 20 days a month 45 weeks a year)

OR

Taking care of a 55 yo with diabetes, hyperlipidemia, hypertension, coronary artery disease, chronic renal insufficiency, who is depressed, has a rash, erectile dysfunction, esophageal reflux and who is taking care of his elder mother with Alzheimer's dementia.”

I just had the opportunity to review the charts of the patients seen by one of my first-year family medicine residents in one clinic session recently. They included:

· Woman with uncontrolled Diabetes, recently discharged from the hospital with diabetic ketoacidosis; marked edema of legs.

· Woman with anhedonia who feels “fat and alone”; no “physical abuse” – boyfriend just pushes her and she feels safe when she locks the door.

· Woman for “well-woman exam”, who came for Pap smear and prevention, with uncontrolled hypertension, very stressed from working her two jobs, having difficulty with her medication.

All had, in addition, other medical problems.

“Uncomplicated” primary care”? Perhaps you would like to take over the comprehensive management of her patient panel, Dr. Cooper?

[1] Baicker K & Chandra A, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care”, Health Affairs, 7 Apr 2004;W4.184
[2] [3] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502
[3] Ferrer RL, Hambridge SJ, Maly RC, “The essential role of generalists in health care systems”, Annals of Internal Medicine 2005;142:691-699.
[4] . Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.
[5] Goodman DC, Grumbach K. Does having more physicians lead to better health system performance? JAMA. 2008;299(3):335-337.
[6] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380

[7] Cooper RA, “States with More Physicians Have Better-Quality Health Care,” Health Affairs 28, no. 1 (2009): w91–w102
[8] Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL., Primary care: is there enough time for prevention?, Am J Pub Health, 2003 Apr;93(4):635-41.