The perils of discerning 'expert medical opinion'

A recent article in the British Medical Journal titled "Is there an (unbiased) doctor in the house?" adds to the barrage of stories suggesting that when it comes to an expert medical opinion, something is gangrenous in Denmark.

The problem has more to do with accounting than medical science. With increasing frequency, physicians who are recognized as leaders in their respective specialties are developing strong financial ties to the pharmaceutical or medical-device industry. Some of these experts will be recruited by health-care businesses to become "KOLs" – key opinion leaders, after which they'll be groomed to be "on message" and then paid to give expert talks to other physicians in the community.

A personal essay by psychiatrist Daniel Carlat in the New York Times describes the egoic and financial allure, and the soul-bending pressures, that come with the KOL job.

While the stated objective for KOLs  is education – these physician experts are allowed to say whatever they care to about any given drug or device – as a practical matter, these "thought leaders" have been hired to meld physician practices. So much so that the pharmaceutical industry tracks drug sales in each individual KOL's speaking area; if the drugs don't move, the money and the speaking engagements dry up. Carlat stepped away from his KOL role under such pressure.

Media seek them out
For obvious reasons, these key opinion leaders are often the people whom the media seek out as sources for their stories. As the BMJ article and others have pointed out, the KOLs' expert qualifications often make it to print, but their financial ties to the companies manufacturing the drug they're promoting rarely do.

That's why the authors of the BMJ article compiled a list of around 100 "leading independent medical experts," a kind of Angie's List for medical journalists looking for an unfettered expert opinion. Those included on the list had to affirm that they hadn't taken any financial support in any form from the pharmaceutical or medical device industry over the preceding five years.

As Iowan songwriter Greg Brown croons, there are foxes in the henhouse, and cows in the corn, and the media can't seem to tell the difference. Why not?

That's the question I posed to Gary Schwitzer, director of health journalism at the University of Minnesota's School of Journalism and Mass Communication.

Schwitzer is on the leading independent-medical-expert list. In fact, he's part of the trio that screens applicants to the list, and he's qualified to do so because medical media malfeasance is something he knows a lot about.

In April 2006, Schwitzer created HealthNewsReview.org, a web-based organization dedicated to scrutinizing the health news coverage of 50 major newspapers – the Associated Press, Newsweek, Time and U.S. News & World Report, and the evening news broadcasts of ABC, NBC and CBS.

An unscrutinized free ride?
I asked Schwitzer, don't they teach this stuff in journalism, that all sources – even physicians – have their biases? Have the media been giving physician sources an unscrutinized free ride?

"Health-care journalism gets treated the same [as other news subjects] too many times, when it should not; and it gets treated differently from other beats too many times when it should not," Schwitzer explained.

How so?

"It gets treated the same in the sense that you can cover the cops and courts and crime beat by just putting your microphone in front of, or getting a quote from, anyone in authority, and go with it," Schwitzer told me.

That works fine for a story about a corrupt sheriff deputy, or a traffic accident, or a string of burglaries, where perhaps any source will do. But in medicine, expert opinion drives health-care practices, with multibillion-dollar implications for our country; and heavy individual, personal implications.

"Where it gets treated differently, though, is that some of the basic fundamental, sound, journalistic skepticism and cynicism that is applied in other beats, like 'Wait a minute: What is this load of bull that McCain or Obama are feeding us?' is not applied to health-care journalism, and I do think that it is [because of] the trusted, compassionate, caring white-coat clinician syndrome," Schwitzer added.

Another driving factor
So there's a lingering Marcus Welby benevolence. But Schwitzer thinks there's something else driving not only the media's choice of sources, but also their choice of medical stories and how they are covered.

"There's another part of it, and I've seen this manifested most often in the non-evidence-based journalistic promotion of various screening tests – for example, PSA, mammography for women in their 40s, a triad of vascular screening tests. In fact there's a Pulitzer-winning team at the Wall Street Journal; because one member of the team had a stroke or some cerebral event a couple of years ago, now suddenly they are out to save the world [by promoting vascular screening tests]," Schwitzer recalled.

"And that's the punch line here: Journalists become do-gooding crusaders, and evidence be damned, how could anybody possibly say that early prevention is not always a good thing? [The media say,] 'We're damned if we do and we're damned if we don't. You say that we don't care about our readers, and here is an episode, or a series of episodes, where we really wanted to help people,' " Schwitzer explained.

"And you just can't pound it into such folks' heads that they might be doing more harm than good, because they've crossed the line. They've crossed the line no matter how you draw it, and in no matter what profession, where evidence does not support the advocacy-crusading stance that they're taking. When you have a public platform and make population-wide proclamations, you are potentially hurting more people than you are helping."

"So yes, there's the Marcus Welby Syndrome," Schwitzer concluded, "but then there's also, 'I'm going to take some of that cloak on myself because I can be a do-gooder journalist.' "

How crusading is manifested
To Schwitzer this journalistic crusading is manifested by not attempting to explain or quantify both the potential benefits and the potential harms of a new therapy; by not reporting the costs of a new drug or intervention; by nabbing bumper-sticker slogans from a new study – "New Drug Shows Potential Benefit in Multiple Sclerosis" – rather than subjecting the same study to rigorous statistical review.

These are some of the 10 criteria that Schwitzer's HealthNewsReview.org uses to grade individual health news stories. The criteria are rigorous (and I'm not sure how well some of my writing would hold up against them) but, without being overdramatic, with millions of lives and billions in tax dollars at stake, what subject deserves more journalistic rigor than stories about health care?

Schwitzer understands that the criteria are rigorous. Earlier this year he wrote a paper that summarized HealthNewsReview.org's first 500 reviews.

The study was rejected for publication by one particular major medical journal because its review board felt the criteria created too high of a standard for journalists and for the physician researchers authoring the studies.

"That's what a leading medical journal would tell you about why they're not going to publish my article," Schwitzer lamented, "because we really need to dumb it down for everybody, including physician researcher authors. It's just mind-boggling."

But Schwitzer is sticking by these criteria, and HealthNewsReview.org presses on.

"What I will always say to journalists is look, we're just a little mom-and-pop place; nobody is working on this full time. We've just put our little stake in the ground and said, 'These are the criteria we think should be applied to every story. If not these, if you disagree with us, for God's sake, let's have a discussion,' " Schwitzer explained. "But while we're at it, what are the criteria you [the journalist] are choosing to use? And it's a very short conversation, because there are none, beyond newsworthiness, broad appeal, and you just don't get down to any meat."

Dr. Craig Bowron is a Twin Cities internist and writer who reports on medical topics for MinnPost. He can be reached at cbowron [at] minnpost [dot] com.