Medical interventions we shouldn't be getting: issues of cost, health, and equity

Many of us are concerned about the cost of medical care, particularly in the US. We are also concerned about the care that we, ourselves or our families and friends receive. We want the diagnostic tests and treatments we get to be likely to benefit us and to not cause us harm. Or, if there is chance that we may be harmed, that the probability and degree of benefit exceeds the probability and degree of harm. Sometimes there can be a tension here: we want to spend less on health care globally (and certainly less on the portion that just goes into the pockets of big corporations, like pharmaceutical companies and device manufacturer, insurers and huge health provider networks), but don’t want to scrimp on things that may benefit us. Especially when we are well-insured and not paying for it directly out of our pocket.

Fortunately, there are many times when these two different interests come together, when tests or treatments that are costly are also of no benefit to us, and may cause us harm. The problem is that sometimes our doctors recommend them to us anyway, or, frankly, we ask for them (because we’ve read about it on the Internet or seen an ad on TV or because a doctor recommended it for our Cousin Shirley who had the same thing, or at least something that sounded a little the same). How can we, as patients, know when our doctors are recommending a test or treatment that is not indicated for us, will not benefit us, may even cause us harm? How do we know when we are appropriately advocating for ourselves as opposed to asking for something inappropriate? It is not easy, but we can try.

One answer is NOT to reject all medical recommendations for diagnosis or treatment, to assume that something “natural” is always right. Medicine can do a lot; it can treat a lot of illnesses that can cause you to suffer or die prematurely. There are many tests that are proven useful or valuable for making diagnoses. Another is to not reject things simply because they cost money (difficult when you don’t have much and they cost a lot), but also not to ask to have them because you have money (or insurance). To a great extent it is asking your doctor questions, asking about the degree of benefit, hoping that they are up to date, trying to question what the likely benefit is from another test or treatment, especially if costly. It also, sadly, means understanding if the doctor themselves, or a company they work for, stands to make profit on the test or treatment, since this creates a conflict of interest (but certainly does not mean that it always or usually isn’t appropriate).

There is an entire medical literature on medical overuse, and your doctor should be familiar with it, or at least the most egregious overuses that are in her/his field. A recent article in JAMA Internal Medicine , “Update on Medical Practices That Should Be Questioned in 2015”, by Morgan et al., reviews some of these.[1] The authors reviewed the literature on articles published in 2014, and came up with 104 that at least one of the 3 thought was very important, and 33 that all agreed were very important. The article reports on the “Top 10”, because this is a nice, round number and because it seems to be a manageable number of things for doctors to remember. Just these 10 represent a lot of excess tests and excess expense.

I will summarize some of these 10 (the ones I feel are most relevant; you can find them all in the article), both to remind doctors and other health care providers who might not have seen it, and because other readers may have had these tests recommended. Before doing so, it is important to review the difference between a screening test, done on the general population (or a subset of it) who don’t have any symptoms, and a diagnostic test, which may be the same test done on someone with symptoms related to what that test tests for. Frequently a test is useful for diagnosis for someone with symptoms but in someone without may not only be of little use, but find “false positives” that end up leading to more testing with more cost and greater risk.

• There Is No Benefit to Screening for Asymptomatic Carotid Stenosis.  None, for screening. Ultrasound or other tests may be of value for people with TIAs or other symptoms.
• Screening Pelvic Examinations Are Inaccurate in Asymptomatic Women and Are Associated With Harms That Exceed Clinical Benefits. Again, none, for screening. You can’t screen for ovarian cancer. I have been trying to convince my residents of this for years, despite their being often taught otherwise by OB-Gyns. This is the part where the provider puts his/her hands inside. It is NOT the same as a Pap smear, which is recommended for screening.
• Head Computed Tomography Is Often Ordered but Is Rarely Helpful. Often finds clinically insignificant abnormalities. Also, often repeated with no added benefit. (“A retrospective cohort analysis reviewed 130 patients admitted for any cause at least 7 times during a 1-year period to a tertiary care center. Patients received a mean of almost 7 CT scans, including 3 head CT scans. More than one-third (36%) of head CT scans were ordered to evaluate for altered mental status. Only 4% (7/127) of head CTs had clinically significant findings that resulted in a change in management.”)
• Thyroid Cancer Is Massively Overdiagnosed, Leading to Concrete Harms.  Study is from S. Korea, where they screen for it.
• There Is No Benefit to Paracetamol (Acetaminophen) for Acute Low Back Pain. “The median times to recovery were 17 days in both of the paracetamol groups and 16 days in the placebo group.” This does not mean we should be using opioids, though. In fact, when we give opioids for good reasons, like postoperative pain…
• Postoperative Opioid Use Continues Past the Postoperative Period.

Some overuse comes because practices once felt to be appropriate, but now shown not to be, are being taught to trainees, who either don’t know or are loathe to disagree with their instructors. Some comes, consciously or not, from the potential for providers to make money. Another recent JAMA Internal Medicine[2] study looked at family medicine and internal medicine residents who saw “secret shoppers”, standardized patients who were requesting inappropriate imaging. About 25% of the time the tests were ordered, which could be seen as either bad or good (75% of the time they weren’t). The study also showed no difference between those residents who got significant feedback and those who didn’t, and similar (and generally good) techniques of communicating to the patients why these were not indicated. An interesting wrinkle is that some of the tests chosen (MRI or CT for new-onset uncomplicated low back pain) were imaging studies not recommended by the American Academy of Family Physicians and American College of Physicians (Internal Medicine) as part of the “Choosing Wisely” campaign, but are not recommended against by the  American Academy of Orthopaedic Surgeons in their “Choosing Wisely recommendations. Of course, orthopedists stand to benefit from doing surgery on these patients. (By the way, among the recommendations of the AAFP is not doing screening pelvic examinations!)

What is the social justice issue here? After all, tests and treatments that are not indicated should not be done on anyone, regardless of financial or insurance status, racial or ethnic characteristics. Indeed, one could argue that those with more money or better insurance would be the most likely recipients of extra tests. But poorer, or less well-insured, people often don’t get the tests and treatments that they actually need (which has often been discussed in this blog; see for example Dead Man Walking: People still die from lack of health insurance, November 17, 2013), while tests and treatments are overused for others. This creates the (accurate) perception of a two-class health care system, and the (sometimes, perhaps, less accurate) perception that the disadvantaged are, in addition to not getting care they need, are not getting discretionary care that benefits the wealthy. Also, the more money spent globally on unnecessary medical care, the less available for necessary non-medical initiatives (housing, food, education) that would actually create better health.

A single payer system would not in itself achieve this goal, but it would create far more equity in the allocation of healthcare dollars, and at least eliminate the profit motive that might impact the recommendations of some providers and healthcare institutions.

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[1] Morgan DJ, Dhruva SS, Wright SM, Korenstein D, Update on Medical Practices That Should Be Questioned in 2015, JAMA Intern Med. 2015 Dec 1;175(12):1960-4. doi: 10.1001/jamainternmed.2015.5614.

[2] Fenton JJ, Kravitz RL, Jerant A, et al., Promoting Patient-Centered Counseling to Reduce Use of Low-Value Diagnostic Tests: A Randomized Clinical Trial, JAMA Intern Med. Published online December 07, 2015. doi:10.1001/jamainternmed.2015.6840

Medical testing: is it about quality?

In her New York Times “Well” blog of April 13, 2015, physician Abigail Zuger comments upon “Quantifying Tests, Instead of Good Care”. She discusses a variety of factors that lead to physicians ordering more and more tests. In part, this is the simply the result of the advance of technology and thus the profusion of tests that can be done --  laboratory tests, imaging (like x-rays and their ever more complex cousins), and even parts of the physical examination (“Yes, little blood pressure cuff over there in the corner, that means you”) --  which sometimes can be seen as meaning they should be done. Other factors are about money. The tests cost money, a negative for patients and insurers, but they make money for the laboratories and imaging facilities and the hospitals which often own them, and frequently employ the physicians doing the ordering. Dr. Zuger notes that “Ordering tests, chasing down and interpreting results, and dealing with the endless cycle of repeat testing to confirm and clarify problems absorb pretty much all our time.”

Another impetus is our desire – patients and physicians alike – to find out what is wrong when there is something wrong. Or, when there is nothing really wrong, to perhaps prevent later disease by finding something hidden lurking inside. There are all these tests we can get! The patient may have had many of them before, ordered by another provider, or know people who have had them. They hope that something will give them an answer. The doctor may feel that there may be an answer out there that s/he might miss if a test is not ordered, or if s/he is a primary care physician that a specialist might order these tests so maybe we should do it first; after all, it sometimes seems as if one thing specialists do when we refer patients to them is order a bunch of tests that we could have. Or, and this is a big focus of Dr. Zuger, that their “quality ratings” may suffer if s/he doesn’t order these tests.

Quality ratings are measures of things that doctors should do (or, sometimes but more rarely, should not do) for patients with certain conditions or complaints; increasingly, insurers, employers, and third-party groups are assessing the quality of care that a physician delivers in this way. Are these recommendations not based on evidence? In many cases, they are. For prevention, the US Preventive Services Task Force assesses the degree to which tests may be indicated or not for different people, often based upon their age and sex. It gives them ratings: ‘A’ is strongly recommended based on good evidence, ‘B’ means there is some, but weaker, evidence to support doing it, ’C’ means there is conflicting evidence and patient preference should be taken into account, ‘D’ means not recommended (might even be harmful), and ‘I’ means insufficient evidence to assess. A smart phone app, ePSS, can be downloaded by anyone; put in age and sex and it tells you which preventive tests are recommended.

Of course, not all doctors do all the recommended screening tests, and frequently they do tests that are not recommended (e.g., PSA to screen for prostate cancer) or more frequently than recommended (Pap smears to screen for cervical cancer), or in people for whom the test is not recommended (mammograms in younger women). When it comes to diagnostic testing rather than screening, looking for the cause of something when the patient is actually ill, there is even less consensus, and often a prevailing attitude of “more (testing) is better”. One effort to combat this is the Choosing Wisely campaign begun by the American Board of Internal Medicine Foundation. This campaign asked specialty societies to identify 5 or more commonly-done tests or interventions in their specialty that should not be done. However, the same recommendations are not always endorsed by every relevant organization. For example, the American Academy of Family Physicians recommends “Don’t do imaging for low back pain within the first six weeks, unless red flags are present.” Great, but neither the American College of Radiology nor the American Academy of Orthopaedic Surgeons, arguably the groups that could make money from this, has such a recommendation.

And then there is the risk. Some of the tests receiving USPSTF ‘D’ recommendations are more than not helpful; they can lead to harm, and this is even more true of the many potential tests that can be done looking for disease. Discussing the work of a collaboration at the Dartmouth Medical School that looks at the utility of tests, Dr. Zuger notes that such iconic treatments as controlling blood pressure can lead to bad outcomes in many older people where the benefits (avoiding stroke and other complications) begin to be outweighed by the risks:  “One study found that nursing home residents taking two or more effective blood pressure drugs did remarkably badly, with death rates more than twice that of their peers. In another, dementia patients taking blood pressure medication with optimal results nonetheless deteriorated mentally considerably faster. Yet no quality control system that I know of gives a doctor an approving pat on the head for taking a fragile older patient off meds.”

This is just the tip of the iceberg. Tests cost money, and often show results that lead to more tests, and then maybe to procedures (biopsies, for example) that maybe show abnormalities that lead to bigger interventions. And, sometimes these interventions are life-saving, but not always. Or maybe, even, not often.  And they do often have side effects, some of which are not insignificant. The person in whom a series of tests identifies cancer and is then treated and then survives is almost always grateful for the testing and the treatment, although in many cases they would have survived just the same with no treatment, and without the costs both in dollars and in side effects. The classic example is prostate cancer, where the evidence of any treatment making a difference in survival is weak at best; it is either a devastating disease from which one dies, painfully, or more commonly a benign condition that one dies with but not from but which treatment seems to have little influence on. Except for the cost, and the non-trivial side effects of impotence, incontinence, and the effects of radiation on the rectum.

Increasingly, data is showing that much breast cancer is similar. As discussed in my December 2012 blog post “More on mammography: just because you don't like the results doesn't make research junk science”, a large study by Bleyer and Welch showed that, with new and more sensitive mammographic screening, many more women are being diagnosed with early-stage breast cancer. However, despite treatment, we are not seeing anything like that reduction in late-stage breast cancer, which means most of those early stage cancers would not have progressed at all. And yet every woman diagnosed and treated sees herself as a survivor who has been cured, even in those cases where progression would not have occurred. In his wonderful recent New Yorker article “Overkill” (May 11, 2015), Atul Gawande notes that we treat all “cancer” as if it were rabbits in a pen who have to be chased down before they escape, when in fact many cancers are “birds” that have flown away and are gone before we can do anything and many others are “turtles” who are not going anywhere whatever we do.

The goal of medical care is now to achieve the “Triple Aim” of high quality, patient satisfaction, and lower cost. As with many things that come in threes, it is not that hard to achieve two but very challenging to achieve all three. Patients satisfaction is important, but not at any cost. Cost control is good, but not if it seriously limits quality. One place to start, then, is with quality, and specifically not doing what is useless or even harmful as assertively as we do what is likely to be of value.

And, of course, to make sure that it is the disease or risk of disease that determines what tests are done, not people’s insurance or socioeconomic status, ethnicity, gender or personality.

Does AAMC have an answer for the primary care shortage? No.

The December 5, 2012 issue of JAMA is its annual “medical education” issue, and contains a number of interesting studies and commentaries for those interested in the topic. In terms of increasing the number of primary care physicians, an issue which I have often addressed, the “original contribution” is “General medicine vs. subspecialty career plans among internal medicine residents”[1] by West and Dupras. This study discovered that only 21.5% of third-year internal medicine residents were planning careers in general medicine (which might be primary care), while 9.3% planned careers as “hospitalists” and 65.3% planned to be sub-specialists (cardiologists, gastroenterologists, pulmonologists, endocrinologists, etc.), with 4% undecided.

This is not a significantly different result from that found by Garibaldi, et al., in “Career plans for trainees in internal medicine residency programs[2] published in 2005 in Academic Medicine, and first discussed by me in “A Quality Health System Needs More Primary Care Physicians” 4 years ago, December 11, 2008. Garibaldi’s number was 27% of 3^rd (final) year residents and 19% of first years. What West and Dupras add is that only 39.5% of graduates of specifically-designated “primary care” internal medicine residencies are actually planning to become primary care physicians.  Apparently all of the discussion about the need for more primary care doctors has not swayed the decisions of these residents, who, at the conclusion of their initial 3 years of training can “go either way”; the way that they are going is to subspecialization.

Commenting on this article, Mark Schwartz (“The US primary care workforce and graduate medical education policy"[3]) notes that, in contrast to internal medicine, a larger percent of pediatric residency graduates, 45%, were planning to enter primary care, which is actually a decrease because of pressures in the discipline to create more pediatric subspecialists. Only family medicine, at over 90%, remains a reliable specialty for producing primary care physicians. Schwartz notes that the Council on Graduate Medical Education (COGME) has recommended a minimum of 40% primary care for an optimally-functioning health system (increased from the 32% at the time of its 20^th report, in 2010), but obviously the movement is in the opposite direction. Moreover, he talks about a 40% “rate” of entry into primary care; however, a 40% entry rate is only a sustaining percent once we are at 40% --an entry rate of 40% will take an entire generation, about 30 years, to yield a 40% primary care workforce. And, indeed, many, including many on COGME, believe that 40% is too low and the actual goal should be 50-60%. Nonetheless, it is all academic when the current rate of entry into primary care will not even replace the current under-30%.

Schwartz also looks at the fact that Medicare supports the majority of graduate medical education through two related programs, Direct Graduate Medical Education (DGME) funding, about $3B, which is to support resident salaries and teaching costs, and Indirect Medical Education (IME) funding, about $6.5B, which is intended to compensate hospitals, the primary sponsors of residency programs, for the increased costs involved in providing patient care in a training environment. Unfortunately for these hospitals (and other program sponsors), the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare policy, has indicated that IME payments exceed the cost differential by $3.5B. There are various proposals for what to do with this money; while MedPAC advocated using it for a pay-for-performance program for GME, both Simpson-Bowles and the administration have advocated using it to pay down the national debt (i.e., chopping it). The Association of American Medical Colleges (AAMC) wants to use it to increase the supporting number of residency positions, currently capped by the balanced budget amendment at 98,000, correctly noting that although the number of graduates from US medical schools is increasing (through class size expansion and opening new schools), this will not increase the number of physicians if the number of residency slot is constant.

Darrell Kirch, President of AAMC, avoids discussion of GME in his editorial in this issue (“Transforming admissions: the gateway to medicine”)[4] choosing instead to comment on an article by Kevin Eva and colleagues from McMaster University in Canada [5]  about using a technique called the multiple mini-interview (MMI) to increase the admission of students with desirable non-cognitive characteristics (i.e., those not well measured by grades and standardized examination scores) to medical school. Kirch says that “…medical schools are moving toward a broader view of medical school readiness that emphasizes the competencies applicants have demonstrated in addition to their academic credentials,” and that “This change is essential to identify future physicians with the skills and knowledge to manage illness in the 21^st century.”

So what do we have. Not enough internal medicine residents entering primary care. Not enough students entering the only true primary care specialty, family medicine. Expansion of medical school classes to produce more US graduates, but no expansion of residency positions, which will largely mean US grads will replace international medical graduates (IMGs) in residency positions (which may in itself not be entirely positive, as described in yet another article in this issue [6]). On the front end, we have increasing recognition that characteristics other than standardized test performance are the most important for future doctors, but only tepid experiments at changing the selection process.

The AAMC could be at the center of advocating for, and in their member institutions, implementing, some solutions to these problems, but currently the solutions they have proposed are far from adequate. Students will be more interested in primary care if they are selected based on the characteristics that are associated with choosing primary care, not mainly on grades and test performance (which are often inversely associated). This is not what Dr. Kirch is advocating. They will continue to be interested in primary care careers if their faculty and overall medical school experience support and encourage them. Most medical schools do not. Increasing the number of residency positions will not increase the proportion of primary care physicians if the expansion is in all specialties, but only if it is limited to primary care. The AAMC has not backed this idea. Finally, the decision to pursue a primary care career by entering family medicine training, or by opting for primary care on completing internal medicine or pediatric training, will only be achieved if the anticipated income differential is addressed, which will require decreased income for the currently most highly paid subspecialists at least as much as increasing that of primary care doctors. The AAMC does not have a position advocating this.

A wonderful “Piece of My Mind” in this issue of JAMA, “Not born in the USA” by Vijay Rajput [7] addresses many of these issues, including how the increased competition for US residency slots by IMGs will drive their test scores even higher, but how these scores do not really prepare someone to be a “humanistic” physician. The strategies mentioned above, including recruiting and matriculating students concerned about people and interested in primary care and care of the underserved, supporting them through their education, offering increases in residency slots only for primary care, and reducing the income differentials for primary care, will address the problems.

Medical schools, the AAMC, and the various agencies of the federal government (especially the Center for Medicare and Medicaid services) need to fully commit to these strategies. It is time for the talk to lead to real action.

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[1] West CP, Dupras DM, General medicine vs subspecialty career plans among internal medicine residents. JAMA. 2012 Dec 5;308(21):2241-7. doi: 10.1001/jama.2012.47535

[2] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12

[3] Schwartz, MD. “The US primary care workforce and graduate medical education policy”. JAMA 2012 Dec5;208(21):2252-3.

[4] Kirch, DG. Transforming admissions: the gateway to medicine. JAMA 2012 Dec5;308(21):2250-1.

[5] Eva KW et al., “Association between a medical school admission process using the multiple min-interview and national licensing examination scores”. JAMA 2012; 308(21):2233-40.

[6] Traverso G and McMahon GT, “Residency training and international medical graduates: coming to America no more”, JAMA 2012; 308(21):2193-94.

[7] Rajput, V. “Not born in the USA”. JAMA 2012; 308(21):2197-98.

"Abandoning ship": is debunking ineffective screening and therapy removing hope or just removing risk?

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Sometimes I think I sound like a real medical nihilist, since many of my blogs have been about purported treatments that are ineffective, dangerous, done too often, and cost a lot of money (Cardiac stents and profit-driven corruption: do anti-fraud rules address the problem?, December 24, 2010; Greed, corruption and medical procedures: ignoring or suppressing the evidence?, August 12, 2011; Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?, March 15, 2011).  It is a somewhat distressing feeling. I am a doctor; I want to help people, to relieve their suffering, to help facilitate the cure of their diseases. More than that, I am a family doctor, and have a strong preference for prevention, for early detection of disease when it is still treatable rather than waiting for it to be too far gone for treatment to be effective. In addition, I have regularly criticized our health non-system for leaving out too many people, creating financial disincentives for them to seek care early. This leads to their waiting until their diseases become so uncontrolled that they present to the emergency room, then require admission and costly care, making it worse for them (most important) and more expensive for everyone. So I think prevention and early intervention is a really good thing, and it would be great to have tests that could identify disease early in its course so that we can change its trajectory.

But because I want these things to be true doesn’t make them true, as I discuss in the recent post Avastin®, Plan B®, and Magical Thinking, December 31, 2011. Because we can screen you for something doesn’t mean that we should; because a test can be done doesn’t mean that it is a good test. "A good test", in my opinion, is one that has sufficient sensitivity (rate of being positive when a condition is present) or specificity (rate of being negative when a condition is absent) to tell us whether a you have a disease, or if it matters. Because it can be done also doesn’t mean that it is cost-effective. Because a treatment exists doesn’t mean it is a good treatment, a safe treatment, an effective treatment. And, as with most things being sold, the greater the publicity and advertising around it, the more it means someone will be making money on it, which does not exclude its being of benefit, but is certainly not the same thing.

Sometimes, when evidence is discovered that a test or treatment is not of benefit, eventually we stop doing it. "Eventually", however, may be a lot longer than you might think. In a recent “Viewpoint” in JAMA, Prasad, Cifu, and Ionannidis address “Reversals of established medical practice: evidence to abandon ship”[1]. They note that while “Ideally, good medical practices are replaced by better ones, based on robust comparative trials in which new interventions outperform older ones and establish new standards of care. Often, however, established standards must be abandoned not because a better replacement has been identified but simply because what was thought to be beneficial was not.” They go on to discuss a number of treatments that have been “standard of care” but were shown by good, randomized controlled trials, to be ineffective or even dangerous (not to say expensive). These include stenting of coronary arteries for stable coronary artery disease (CAD), postmenopausal hormone therapy to prevent CAD, vertebroplasty for osteoporotic fractures, bevucizamab for breast cancer.

Scarily, but unsurprisingly, “true believers” continued to defend these interventions even after the evidence was clear (their livelihoods depend upon it), and in many cases these treatments continue to be offered and performed. “There are thousands of clinical trials, but most deal with trivialities or efforts to buttress the sales of specific products,” and it is only “Rarely [that]…some investigators find the courage to test established ‘truths’ with large, rigorous randomized trials”. Prasad and colleagues have done many of these latter trials; indeed John Ioannidis is the “guru” of debunking treatments with poor evidence (see David H. Freedman’s article in the November 2011 Atlantic “Lies, damned lies, and medical science.”) The authors have some suggestions, including limiting the role of manufacturers (of drugs, devices, tests) from conducting the trials on them, although they should pay for them: “Large trials of new innovations should be designed and conducted by investigators without conflicts of interest, under the auspices of nonconflicted scientific bodies. Instead of designing, controlling, and conducting the trials, manufacturers may offer the respective budget to a centralized public pool of funding, keeping the trial design and conduct independent.”

Prevention and screening are also subject to the lure of magical-thinking-compounded-by-the-greed-of-the sellers. Screening for prostate cancer with the use of prostate-specific antigen (PSA) testing is a good recent example about which I have written (while the lack of effectiveness of treatments for prostate cancer is would be included in the group of ineffective therapies that Prasad and colleagues have written about). Pap smears are pretty good screening tests for cervical cancer, but most other cancer screening tests (even mammograms and colon cancer screening, probably the next best) are not nearly as good. Every time there is a recommendation to decrease the frequency of screening (Pap smears, mammography) or not do them at all (PSAs or pelvic exams) there is an outcry from people who think that something has been taken from them. In a scientific sense, what has been taken is unnecessary testing that doesn’t lower their risk of bad outcomes, costs money, and can have significant morbidity when positive screens need additional, more invasive tests, to follow up. But, in a more metaphysical sense, what has been taken is hope, the idea that there is something that they can do that will prevent something bad from happening to them. Something that, while perhaps a little risky (if you understand or believe it), is relatively easy. And also, frankly, something someone else, rather than you, can do. Not like, say, dieting or giving up smoking or exercising. And this false concept is encouraged by half-truths promulgated by passionate advocates of interventions with limited proven benefit, whether traditional allopathic or “alternative”.

Even public health advocates sometimes get so passionate about the health benefits of what they are advocating that they may miss other issues. For example, consider a recent discussion on a progressive public health listserve about “portion control” (limiting the amount eaten at one sitting). This is an important and effective method of addressing obesity, which is in fact a major health problem in this country, but the discussion raised many other issues. These included concerns about “blaming the victim” -- expecting self-control (difficult enough) from people who had historically not had that control in the face of major initiatives by fast-food purveyors to push large portions. Another was the economics involved in asking poor people to pay “more for less” while corporations continue to make huge profits from them. It can, and often is, as difficult for public health advocates to recognize problems arising from their positions and passions as it is for providers or manufacturers to back off from theirs.

The difference, of course, is that the former are really invested in the health of the public, while the latter are invested mostly in, well, their investments.

[1] Prasad V, Cifu A, Ioannidis JPA, Reversals of established medical practices: evidence to abandon ship”, JAMA 4Jan2012;307(1):37-8.

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