Full of Doubts

I absolutely detest the healthcare “infotainment” industry. You know who I’m talking about: Those celebrity doctors who regularly dish out medical advice on TV, in print, or on the Internet. They make every new remedy sound like a breakthrough, and they’re so quick to recommend the latest procedure, screening test, or concoction. If you’re like me, you are spending more and more time dealing with patients who have bought into a questionable medical claim or recommendation.

To make matters worse, so much of the information that patients receive in the popular media is simply wrong—or at least unsupported by science. Last December, an analysis published in The BMJ found that nearly half of the recommendations on The Dr. Oz Show had no supporting evidence or were contrary to the best available evidence. Unfortunately, many patients place great confidence in the advice they receive from celebrity doctors. After all, if it’s on TV (or the Internet) it has to be true. Right?

The problem with celebrity doctors is more than just their dubious advice. What bothers me the most is their astounding confidence, and how this makes it much more difficult to counter their unsubstantiated claims. The philosopher and social critic Bertrand Russell once lamented, “The whole problem with the world is that fools and fanatics are always so certain of themselves, and wise people so full of doubts.” This is also the source of our difficulty when combating unscientific medical advice. If we are honest with our patients—and ourselves—we have to admit that we have doubts about a great many things.

Consider all the medical advice that we were so certain about that later proved to be unsound. Every child with otitis media does not need an antibiotic, and people at risk for heart disease do not have to avoid eating eggs. Once upon a time we encouraged menopausal woman to take hormone replacement therapy thinking that this would not only make them feel better (which it did) but also prevent heart disease (it did the opposite). For years we pressured men to have digital rectal exams and PSA tests believing that early detection of prostate cancer would save lives. Subsequent studies showed that the harms of screening outweigh the benefits. We were wrong about all of these, and more.

Perhaps this is why so many patients turn to the confident pseudoscientist when they want medical advice. The celebrity doctor is not encumbered by doubt and never has to reexamine and revise his claims. Patients want straight answers to their health-related question, but in many cases, our answers are fuzzy and tempered with uncertainty. It’s a lot easier to tell a patient to go ahead and get the PSA test than it is to steer them away from testing by explaining the concepts of lead time bias and over-diagnosis. It’s tempting to cling to paternalistic certainty, abandon our doubts, and refuse to question our long-held beliefs.

Apparently a significant number of physicians fall victim to this temptation. The Institute of Medicine estimates that about one-third of all healthcare spending is wasteful or unnecessary. This embarrassing recognition was the impetus for the Choosing Wisely campaign. Launched in 2012, Choosing Wisely is a joint effort by medical specialty societies (including the AAFP), Consumer Reports, AARP, and other advocates to advance "a national dialog on avoiding wasteful or unnecessary medical tests, treatments and procedures." Choosing Wisely compiles lists of evidence-based practice recommendations for providers. It also produces patient-friendly resources that can assist physicians in educating patients about tests, treatments, and procedures that should be avoided.

On their web site you can find patient handouts that explain why CA-125 isn’t recommended as a routine screening test, why most people don’t need an antibiotic for sinus infections, and why Lyme disease tests are often a waste of money. Choosing Wisely is a welcome addition, and a useful tool for helping patients understand the limitations of specific medical interventions. Unfortunately, the broader issue of educating patients about the uncertain nature of medical science remains unresolved.

Despite the glamor and charming confidence of celebrity doctors, patients still place their trust in the wisdom and honesty of their family physician. That is why it is incumbent upon us to hold strictly to scientific principles, stay current with the best available evidence, and always nurture a healthy sense of skepticism. This is probably our best hope for immunizing patients against pseudoscience and quackery—but I have my doubts.

This article was published in South Carolina Family Physician.