When evidence says no, but doctors, patients, and the system say yes

There is an interesting article from ProPublica called When evidence says no, but doctors say yes making the rounds about the number of doctors who disbelieve, or don’t know, or don’t care about the medical evidence to the detriment of patients. I do not find any fault with the article. I rail against this daily. I have my whole professional life. It is actually a big reason why I blog because I hear regularly “I didn’t know that” from providers or “If I had only known,” from patients.  I love when people tell me they took in something I wrote to show their provider. I love when a doctor tells me they turned a post into a handout.

The sad fact is some doctors don’t learn anything new after residency. Yes, they go to continuing medical education (CME) but they do not learn anything.  Here’s one example. I used to lecture very often about herpes testing. It’s a little complex, but mostly because there is so much mythology. I would lay all the evidence out over 45 minutes, dispel the myths that were never even grounded in science to begin with, and then prepare for the always present onslaught of questions and shaking heads. At times I wondered did they not understand, but they were doctors and I didn’t see how that could be possible?  Were they not listening? Possibly, although many of these lectures were pre laptops and smart phones so distractions were minimal. Did they not believe me? Oh yes. Some would argue with me afterwards about how I could not be right, meaning they didn’t believe the irrefutable basic science I presented as well as the clinical studies. As Spock would say, fascinating. Whenever I give a lecture, and I am considered to be an entertaining speaker, I consider myself successful if I can get 2-3 doctors in a room of 30 to change one thing about their practice.

Some doctors didn’t get good information in residency. A good example in OB/GYN is the belief that IUDs are not acceptable for women who have never been pregnant. Studies disproving this are over 20 years old and yet a 2014 study indicated that 32% of doctors did not believe IUDs were safe for women who have not been pregnant. THIRTY TWO PERCENT. I guess they were taught by someone who didn’t know and so on?

Undoing incorrect information is hard. There are articles written about anchoring. getting stuck on the first diagnosis and when treatment fails a doctor assumes the treatment was ineffective and keeps prescribing more and more treatments instead of taking the other road and questioning the diagnosis. As a sub specialist I can tell you the wrong initial diagnosis is most common thing I see in my field.

On top of it the science is not always good and Big Pharma controls a lot of the funding and of course what data gets released, so we may be making decisions with biased information.

Sometimes  doctors are just jerks. Two years ago my then 86-year-old father had a mycotic femoral aneurysm and needed emergency surgery that took 6 hours. The day after surgery there was a concern he may have had a heart attack during the procedure. Was it from the cardiac stress of the long surgery with a lot of blood loss or did he have blocked vessels? He had normal cholesterol, before the surgery could ride his bike for several miles, had normal blood pressure and no one in his family has ever had a heart attack. His dad lived to 98 and he had a 92-year-old brother. I was told he needed a cath by a surgical resident over the phone as I ran to catch the plane to see him. He would have to be transferred to another hospital to have the procedure.  All kinds of complications flew through my head. “Could I just speak with the cardiologist,” I asked? I just wanted to know the complication rate and what would happen if he did and if he did not have the procedure. The cardiologist refused to speak with me. He even refused to see my dad, all of this decision making was made speaking with a resident. Instead of answering my simple questions and seeing my father the cardiologist cancelled the cath. I was furious. All I had done was dare to ask he see my father and give me some information about risks and benefits. What if my dad died because I had just asked for data? Turns out my dad didn’t need the cath because here we are two years later and my dad is 88 and walking a little more slowly because of his femoral nerve injury, but he’s up and about and still has never had any chest pain. However, this is not an ideal way to have this outcome.

Then there is also money. Some surgeons do an awful lot of hysterectomies while others seem to be able to manage their patients with a much lower rate of surgery. I assume this holds in all surgical fields and not just gynecology. I have heard surgeons say about a not indicated surgery, “Well, If I don’t do it someone else well, so I may as well do it right.” And then, “Who knows, maybe it will help?”

Who knows? What if your pilot said, “Who knows, maybe we’ll land the plane safely?”

Some doctors follow guidelines and some do not. The preferred method of hysterectomy is vaginal according to national guidelines, but hey the robot is cool! Hospitals have to pay for them, so they are advertised as state of the art because you have to pay the upkeep. Patients are happy because they think they are getting the best! Insurers don’t seem to balk at the necessary expense. How does this happen?

But there are other issues too.

Sometimes doctors feel pressured to do something when they have no real medical therapy to offer. The art of doing no thing has been lost.  The urge to help can trump the need to sit on our hands and listen. Doctors are also worried about their patient satisfaction scores, either at work on online. An unhappy patient can leave lots of terrible comments and two or three can affect your salary or at the very least leave you answering to your superiors. If you don’t think the drive to make patients or administrators happy changes medical practice then you are wrong.

Pills and surgeries are “easier” for everyone. Providers, patients and insurers. It is my experience that in general people are happier when they leave with something tangible. A prescription validates the symptoms perhaps? Maybe it validates the time off of work ? However, many things have no easy answer. For example, talking about sleep hygiene is hard. When I tell people about turning off the screen or what they need to do if they are staring at the clock I have received eye rolls. How could a behavior change fix something that is so devastating? People who don’t want pills generally don’t come to the doctor, so we do see many people who are biased towards wanting medical interventions. Some people turn to yoga or cognitive behavioral therapy for their insomnia without ever making a doctor’s appointment.

And what about that knee pain? It hurts so much. How could physical therapy help something that painful? So there is that hurdle. Then there is the co payment for physical therapy, it can be $100 or $150 and there may be 8 or 10 visits as well as daily home exercises to see improvement and maybe weight loss is needed too. However, what if someone dangles a surgery with a $250 co payment? The doctor wouldn’t offer it if it wasn’t helpful, right?  It is pretty easy to see how people, including even well-meaning surgeons, convince themselves that surgery is the answer because it is easier to get a unindicated MRI and a unindicated knee or back surgery in almost every single health system than it is physical therapy and cognitive behavioral therapy. The path of least resistance is rarely the right one and that is terrible.

I have spoken with patients who have had a clearly unindicated surgery who are no better and yet many are perfectly satisfied with the unhelpful surgery. In fact they are happy because they equate the surgery with their doctor taking their complaints seriously and trying something. The bigger the intervention the less unhappy people seem about it not working.

We all believe what we want to believe. If patients don’t come back after surgery, it must have helped, right? If your cold or cough went away after antibiotics, they must have helped, right? I was ill for a week or two before I went to the doctor because I didn’t want it to be pneumonia. In my field multiple studies tell us that self diagnosis of yeast infections is very inaccurate and that women are wrong about 70% of the time, which is worse than flipping a coin. Trying to convince someone over the phone they need to be seen when they don’t want to be because they are convinced they are right is hard and time-consuming. Everyone, doctors included, often refuse to believe statistics apply to them. I get the competing pressures of work and co payments and convenience, but I am seeing a rise in resistant yeast and I am scared for my patients and I want to do the right thing medically. Some people yell at me. Some write nasty things. Some doctors just stare at me in disbelief that self diagnosis of yeast infections is wrong. Others thank me for caring and being dedicated to giving them the right therapy.

If blogging for six years has taught me anything it is that everyone, not just doctors, want to believe what they want to believe. When people can reply to you anonymously you hear a lot more than you hear in the office. I delete so many nasty comments from people who accuse me of lying about iodine allergies or vaginal Valium or vaccines. Some people even believe walking around wearing a vaginal jade egg helped them. I often close comments because of that very issue, the rancorous minority claiming a therapy works for them can change the minds of others. Disbelieving evidence, it seems, is a very human trait. If it were not people like the Medical Medium, who gets his health information from a ghost, would not be a best-selling author.

People often want a unifying diagnosis for their symptoms. Some people don’t want to have depression or fibromylagia or hear that sleep hygiene can help, a unifying diagnosis of chronic Lyme disease or heavy metal poisoning or chronic EBV has “real” treatments. It’s taking symptoms seriously, and so charlatans profit.

I have no easy answers. It’s not just medical education that needs overhauling and empathy training and interpersonal skills. We have to stop publishing lower quality articles. Fewer journals with more rigorous peer review would be great, but then how will doctors keep their academic jobs? It’s publish or period, not publish quality or perish. Wouldn’t it be better to have one amazing article that changes lives than a bunch of crappy ones?

The press also needs to stop writing about case reports and articles with seven patients. People read those headlines and insist on that therapy.

We need to do something about direct to consumer advertising. It’s not helpful.

Magazines and life style websites and physicians with platforms, yeah Dr. Oz I’m talking to you, need to stop giving voice to ludicrous therapies and ideas like wheat or EBV or chronic yeast or vitamin D3 or whenever the new whipping boy is that is causing every autoimmune condition. By the way no one seems to have grain brain in France.

We need more government investment in high quality clinical trials, but are we willing to pay more taxes for it?

We need vetted sources of quality information. Again, that will take tax dollars.

We need professional societies to take stronger stances on what constitutes high quality therapy, what is not, and to be honest about gray areas and we need those guidelines to be handed out to patients.

We need investment in health literacy.

We need doctors trained to understand studies, to stay up to date in their fields and who can communicate, and who are also trained when needed to do no thing. They also need more than 15 minutes to listen, communicate, and treat, but again, that will cost more.

Doctors are certainly part of the problem, but saying it’s all on doctors is like saying global warming is only from coal. There are lots of industries involved and every single one of us has a carbon footprint.

Doing the right thing in medicine is almost always the hardest thing. Not because it’s hard medically, but because life and the medical system have set it up that way. Until that changes care will still vary from state to state and office to office and person to person and whether you live or die might depend on what search terms you entered into Google and that is just wrong.