Here are two headlines on the same New England Journal of Medicine article this week, on a study from Johns Hopkins.

The local paper - the Baltimore Sun - had the cheerleading headline: "Hopkins study supports use of CT scan of heart."

The Wall Street Journal, on the other hand, had a quite different headline: "Heart scans sometimes fail to identify blockages, study finds."

Granted, the Baltimore story had some strong caution, such as this quote:

"I think [the study] is overly optimistic about CT angiography," said Dr. Steven E. Nissen, a cardiologist at the Cleveland Clinic. "In the real world, as opposed to in a carefully designed study, CT angiography does not perform as well as was reported in this study."

But the headline sets reader expectations of what is to follow. We think the WSJ outshined the Sun on this one.

All over the country, daily journalists working on newspapers or on radio or TV are now also being asked to publish blogs - often without any additional pay for the additional work.

But I recently discovered a case where a reporter pressured to do a blog had that blog censored by a TV news director because he didn't like what was in the blog.

The reporter - a TV health reporter - posted two entries about some questionable (I would call them unethical) practices in TV news. One referred to the practice of medical centers buying air time within newscasts and having the message appear as news. The posting asked blog visitors:

"What do you think of commercials for local health care behemoths that look like news? ... Are you able to tell they are clearly commercials?"

The other blog entry was about subscription services that provide health news for stations to fill their newscasts. The reporter, whose station often uses such a service, wrote on the blog:

"I've noticed a lot of the subscription reports have to do with research. And not that I have anything against research -- in fact, I think it's a very important part of medical advancement -- but I believe the mass media need to be very careful about highlighting investigational procedures, products, and techniques. ...I worry sometimes these packages peddle false hope, or at least, premature hope.

What do you think of these subscription pieces? Can you tell when it's something I've written versus a (subscription) piece? Do you think stations should even subscribe to (such) services?"

Without being told in advance, the reporter noticed that the blog entries had been deleted. The news director then called the reporter on the carpet and said that "He didn't think it was right to ask viewers what they thought about something management had already decided to do."

The reporter no longer blogs on the station website. That reporter asks if other reporters have had similar experiences, stating "it's about reporters everywhere having viewpoints about what their own industry does, and not being able to express their views without fear of reprisal."

Please weigh in if you know of other such in-house censorship of the free flow of ideas. In an era of transparency, there are apparently some editorial decisions that some news managers - at least this one - don't want to shine a light on. That may be the best evidence there is for why the practices in question should be re-assessed.

Few news stories gave a comprehensive picture of the findings published in the New England Journal of Medicine last week from  the Jupiter study.  This was the well-publicized study of the use of the C-reactive protein test (CRP) in “apparently healthy people” and the use of the drug rosuvastatin.

This story presented a classic case of how our ten criteria should be applied in coverage of new treatments.

• Give absolute, not just relative risk/benefit data.  Many stories reported, as the New York Times did, that drug recipients “were also almost 50 percent less likely to suffer a stroke or need angioplasty or bypass surgery, and they were 20 percent less likely to die during the study.” But few reported – as the New York Times did not - that the absolute risk reduction was only 1.2%.  Few reported the number needed to treat:  that more than 100 people would need to be treated for two years in order for one to benefit.  Relative risk/benefit figures always make the effect size seem bigger.

• Costs.  Few reported the drug cost of $1,250 a year or $285,000 per event prevented.

• Conflict of interest.  Some reported that the study was funded by Astra-Zeneca and that the principal investigator holds a patent on the CRP test that would lead to more people being prescribed statins.  But it took blogger Merrill Goozner to drive home the overlap of cost and conflict of interest when he wrote:

“If they can get two million more "apparently healthy men and women" on rosuvastatin, it's an additional $2 billion-plus in sales for AstraZeneca. If they can test 10 million people to find the estimated two million with elevated CRP levels (they had to screen nearly 90,000 people to find the 17,800 eligible for the trial), it's $200 million in test sales, which, if the royalty is only 1 percent, amounts to a hefty $2 million a year in extra income for Dr. Ridker (the principal investigator).”

• Alternative options.  Few reported on the drug studied (rosuvastatin) compared with other drugs. 

Criticism of many stories could mirror our review of a Los Angeles Times story:

 “This news report about a significant clinical trial on statins and heart disease fails to look skeptically at the claims of the self-interested researchers. Rather than pushing back against the exaggerated claims of efficacy, safety, and imminent transformation of treatment protocols, the report magnifies them. 

The report's failures are largely due to emphasis rather than omission. The caveats are noted, but buried or otherwise minimized. …In all, 16 paragraphs make positive statements about the results. Four paragraphs call the findings into question.”

Meantime, there were three important articles last week about health journalism. 

1) In the BMJ , Steve Woloshin, Lisa Schwartz and Ray Moynihan raise new questions about "who's watching the watchdogs?" Excerpts:

    "Industry sponsorship of training and further education of journalists now occurs in a variety of contexts—universities, conferences, and professional associations—raising similar concerns to those that apply to education of doctors.

    The University of North Carolina’s master’s degree in medical journalism, one of the first in the United States, has at least two important forms of financial relations with drug companies. ...

    Like some university programmes, the American Medical Writers Association, whose members include reporters and public relations specialists, receives sponsorship from the drug industry. Eli Lilly was a key sponsor of the association’s 2008 annual conference, and the company also sponsors its student scholarships.
    ...
    One of the more astonishing forms of financial ties between journalists and drug companies is the sponsored award, which often involves lucrative cash prizes or opportunities for international travel. For example, Eli Lilly and Boehringer Ingelheim have co-sponsored an award for "reporting on urinary incontinence," carrying a prize of international travel. Boehringer has an award for reporting on "chronic obstructive pulmonary disease," offering prizes worth $5000 each, Eli Lilly one for reporting on oncology, and Roche one for "obesity journalism," with a prize of $7500. Sometimes awards are sponsored by organisations that are themselves heavily funded by industry, such as the non-profit Mental Health America. Its 2007 annual report shows that almost half of its funds came from drug companies, including more than $1m each from Bristol Myers Squibb, Lilly, and Wyeth.
    ...
    A powerful contemporary example of entanglement involves a television network called Accent Health (whose logo includes the words "Your target is waiting"), said to be watched monthly by more than 10 million viewers in US medical waiting rooms. The network, which is produced by CNN, overtly offers sponsors, including drug companies, the chance to boost sales of their products, by, for example, putting "your brand in front of the valuable Baby Boomer population just before they discuss their health conditions with their doctor." One of the hosts is Sanjay Gupta, CNN’s chief medical correspondent and host of at least one other CNN health programme that is funded partly through drug company advertising. ...

    As researchers and writers acting to improve medical journalism, we encourage journalists, educators, and professional associations to scrutinise their own relations with the industry as intensely as they do those between doctors and drug companies and to develop workable solutions. And, if they are to be good watchdogs, journalists need to mark their territory and clearly establish boundaries between themselves and the industry to avoid unhealthy entanglements."

2) Journalist Cris Russell wrote "Science Reporting By Press Release" for the Columbia Journalism Review.

3) Finally, in a related note, see the Slate piece, "Bullies Like Bullying: How did a nonstory based on an iffy study end up in a New York Times blog?"

It’s refreshing to see these three pieces reflect on health care journalism practices.  Thanks to all for enriching the discussion.

"Anemic." That's what the Wall Street Journal Health Blog calls the fact that health news made up 3.6% of all the news content analyzed by the Kaiser Family Foundation and the Pew Research Center’s Project for Excellence in Journalism over an 18-month period ending in June.

One data point I locked into is this:

Despite ongoing debates about the future of our health care aystem, health did not become a dominant part of the 2008 primary campaign narrative. Looking at all of the presidential campaign coverage over the first six months in 2008, health-focused stories made up less than 1% of the coverage.

While the analysis ended in June, I'll go further and predict that a systematic analysis of the June - November period would show that health policy coverage didn't improve any.

The report concludes:

"Given the small portion of national news information that is dedicated to the health care system, it may be difficult for the public to become fully knowledgeable about the state of our system and potential changes under debate."

See the full report here.

Earlier this year, when I published our data on our first two years' experience on the HealthNewsReview.org project, I thought that surely leading U.S. journalism publications such as Columbia Journalism Review or American Journalism Review would be interested in some kind of summary.

Wrong. Not a word of interest.

But internationally, journalism bloggers from several countries picked up on the story immediately. And now a German journalism magazine, Message: Internationale Zeitschrift für Journalismus, has republished the PLoS Medicine article.

I hope we can get an international discussion started - backed by the experiences of my colleagues on the Media Doctor Australia and Media Doctor Canada projects.

Our combined pool of news stories reviewed in the 3 countries now totals over 2,000 - a very clear picture which shows how many news stories across the globe fail to deliver important details on health news stories such as:

• How much is this going to cost?
• How small is the potential benefit?
• How large are the potential harms?

Capping quite a week in criticism of health-medical-science journalism (see my two previous posts), Slate offers a column, "Bullies Like Bullying: How did a nonstory based on an iffy study end up in a New York Times blog?" Daniel Engber's column targets the work of New York Times health blogger Tara Parker-Pope. Excerpts:

"Last Wednesday, she posted about a team of neuroscientists from the University of Chicago who had shoved a handful of bullying teenagers into an fMRI scanner to see what was going on inside their heads. "In a chilling finding," she wrote, "the researchers found aggressive youths appear to enjoy inflicting pain on others."

Bullies like bullying? I just felt a shiver run up my spine. Next we'll find out that alcoholics like alcohol. Or that overeaters like to overeat. Hey, I've got an idea for a brain-imaging study of child-molesters that'll just make your skin crawl!"

In this case, I'm less interested in the science than the lamebrained science journalism. The New York Times did something worse than covering a nonstory—it shamelessly promoted it. Take another look at Parker-Pope's write-up, and now read the University of Chicago press release that went out the week before. Three entire paragraphs (including an extended quote) make it from the release into the six-paragraph Times post, virtually unchanged. The rest is paraphrase.

It's no wonder she missed some potential flaws in the bullying study. A quick look through the archives suggests that Parker-Pope makes a regular practice of touching up university-wire stories without any discernable reporting of her own. On Oct. 29, she posted on a study of stress and decision-making in seniors. The material was reworded slightly, but all of it—including the quotes—had previously appeared in a USC press release. In this piece from Nov. 4 on a study showing that children are safest under their grandparents' care, she acknowledges pulling a quote from a Johns Hopkins release but never acknowledges that the rest of the information she cites also appears in that release. Same goes for a Nov. 10 post on how drivers respond to speed limits, which consists entirely of information that appeared in a release from the Purdue University news service.

I don't mean to suggest it's a crime to take material from a press release. But it's certainly lazy, and there's every reason to believe that Parker-Pope knows better. In her short tenure at Well (and in her previous gigs), she's shown a knack for smart and skeptical science coverage: Posting on a study of how television affects teen pregnancy rates, she goes out of her way to complicate the sexed-up angle from the press release. Indeed, two years ago, she informed the Columbia Journalism Review that, "as reporters, we should never take anything at face value. I think a mistake that a lot of people might make is to read the press release. I almost never read the press release."

Go to the link above and read the entire column. The hyperlinks on the Slate site add depth to this discussion.

In the BMJ this week, Steve Woloshin, Lisa Schwartz and Ray Moynihan raise new questions about "who's watching the watchdogs?" Excerpts:

"Industry sponsorship of training and further education of journalists now occurs in a variety of contexts—universities, conferences, and professional associations—raising similar concerns to those that apply to education of doctors.

The University of North Carolina’s master’s degree in medical journalism, one of the first in the United States, has at least two important forms of financial relations with drug companies. ...

Like some university programmes, the American Medical Writers Association, whose members include reporters and public relations specialists, receives sponsorship from the drug industry. Eli Lilly was a key sponsor of the association’s 2008 annual conference, and the company also sponsors its student scholarships.
...
One of the more astonishing forms of financial ties between journalists and drug companies is the sponsored award, which often involves lucrative cash prizes or opportunities for international travel. For example, Eli Lilly and Boehringer Ingelheim have co-sponsored an award for "reporting on urinary incontinence," carrying a prize of international travel. Boehringer has an award for reporting on "chronic obstructive pulmonary disease," offering prizes worth $5000 each, Eli Lilly one for reporting on oncology, and Roche one for "obesity journalism," with a prize of $7500. Sometimes awards are sponsored by organisations that are themselves heavily funded by industry, such as the non-profit Mental Health America. Its 2007 annual report shows that almost half of its funds came from drug companies, including more than $1m each from Bristol Myers Squibb, Lilly, and Wyeth.
...
A powerful contemporary example of entanglement involves a television network called Accent Health (whose logo includes the words "Your target is waiting"), said to be watched monthly by more than 10 million viewers in US medical waiting rooms. The network, which is produced by CNN, overtly offers sponsors, including drug companies, the chance to boost sales of their products, by, for example, putting "your brand in front of the valuable Baby Boomer population just before they discuss their health conditions with their doctor." One of the hosts is Sanjay Gupta, CNN’s chief medical correspondent and host of at least one other CNN health programme that is funded partly through drug company advertising. ...

As researchers and writers acting to improve medical journalism, we encourage journalists, educators, and professional associations to scrutinise their own relations with the industry as intensely as they do those between doctors and drug companies and to develop workable solutions. And, if they are to be good watchdogs, journalists need to mark their territory and clearly establish boundaries between themselves and the industry to avoid unhealthy entanglements.

Cris Russell has a column under the headline above in the Columbia Journalism Review. Excerpts:

"A dirty little secret of journalism has always been the degree to which some reporters rely on press releases and public relations offices as sources for stories. But recent newsroom cutbacks and increased pressure to churn out online news have given publicity operations even greater prominence in science coverage.

"What is distressing to me is that the number of science reporters and the variety of reporting is going down. What does come out is more and more the direct product of PR shops," said Charles Petit, a veteran science reporter and media critic, in an interview. Petit has been running MIT's online Knight Science Journalism Tracker since 2006, where he has posted more than 4,000 critiques involving approximately 20,000 articles. He is concerned that science news "spoon-fed" directly to the media through well-written press releases and handouts has "become a powerful subversive tool eroding the chance that reporters will craft their own stories." In some cases the line between news story and press release has become so blurred that reporters are using direct quotes from press releases in their stories without acknowledging the source. ...

"The problem is worsening," agreed Paul Costello, who heads the Stanford University School of Medicine communications and public affairs office. He said that the "shift to new media Web site traffic" is putting added pressure on reporters, leading some to cut corners in the name of more copy, "often writing right off press releases, even at the good papers." "

I've been tracking news coverage of a Minnesota company's heart "sock" device for heart failure for four years. Four years ago, I questioned Star Tribune coverage.

Two years ago, questions of evidence started to surface.

Today the Star Tribune reports:

"The high-profile consumer advocacy group Public Citizen expressed "deep concern" this week about whether the company's experimental device has been sufficiently reviewed by federal regulators. ...

Two advisory panels for the FDA have recommended against approval of the Acorn device after reviewing the company's application and holding public hearings. The agency itself has rejected the company's application three times. Acorn has even taken its case to a dispute resolution panel, a highly unusual move in the device world, which also voted against approval of its device.

Normally, a company in this situation would have abandoned the rather-expensive effort, especially a start-up like Acorn, which has no other products on the market.

But Acorn has been encouraged along the way by Dr. Daniel Schultz, a surgeon who is head of the FDA's device division, and the company subsequently reached an agreement with the agency to conduct a second, albeit smaller, clinical trial involving 50 patients. If that study is successful, the device could be approved by the agency without being first reviewed by an advisory committee and without a public hearing, according to Public Citizen.

In a Nov. 12 letter to Schultz, Public Citizen said the design of the new study "is so poor that it is unlikely to provide reliable data that would contradict the negative findings of the data so far submitted to the FDA." The number of patients enrolled in the study is too small, and they will not be followed for a sufficient amount of time, Lurie said."

I never would have picked up on the scent of this story had not the Star Tribune given such favorable coverage to the company and its product four years ago.

You can split hairs all you want about what the Associated Press actually reported about an American living in Germany who was treated with a bone marrow transplant for his leukemia, a treatment now being reported to have had an impact on his HIV/AIDS status.

But these words were used:

"Doctors say marrow transplant may have cured AIDS."

"...appears to have been cured of the disease...."

"...he no longer shows signs of carrying the virus..."

Despite some caveats in the story, one can question why the AP reported this story at all.

Perhaps no one remembers as vividly as I do how CNN reported on a hyperthermia "cure" for AIDS back in 1990. I remember because, as head of the CNN medical news unit at the time, key people at the network went behind my back, then spurned my advice, and reported this "cure." It didn't take much and it didn't take long for the facts to show how foolish and how inappropriate that reporting was. That incident was the leading factor in why I resigned from the network within a few months.

Does journalism ever learn about "cures"?

About verification?

About replication of results?

About the impact such stories have on sick people?

OK, turn it over to some journalists and we'll have statins coming out of the kitchen faucet tomorrow.

On HealthNewsReview.org, we reviewed a story on the Jupiter-Crestor-CRP study done by the once-venerable Los Angeles Times. Excerpt of our review:

This news report about a significant clinical trial on statins and heart disease fails to look skeptically at the claims of the self-interested researchers. Rather than pushing back against the exaggerated claims of efficacy, safety, and imminent transformation of treatment protocols, the report magnifies them.

The report's failures are largely due to emphasis rather than omission. The caveats are noted, but buried or otherwise minimized. For example:

* The report states that the study and its lead author are funded by the drug maker. But these facts are added as asides, and follow dramatic claims of benefits high in the story.
* Halfway into the story, the reporter cites unnamed "critics" who "charged" that wide adoption of the treatment protocols would be too expensive to justify. But this is followed immediately by a dismissal and a prediction that the changes will come anyway.
* The report eventually states how many people would need to be treated with statins in order to prevent one event--but this comes long after several enthusiastic declarations and statistical formulations supporting statins' power to prevent heart events and save lives.
* The report mentions a small risk of side effects--but ignores previous reports, including one by the same journalist, that the statin in question has a worse side effect profile than most statins.

In all, 16 paragraphs make positive statements about the results. Four paragraphs call the findings into question.

The story also fails to parse facts about CRP. The study looked at people with presumably safe cholesterol levels but high CRP levels. Because the drugs reduced both cholesterol and CRP, the results are silent on whether the benefits are related to a reduction in CRP. Yet the reporter allows the lead author--who holds a patent on the CRP test used in the study--to make this assertion.

Given the obvious financial interests of the researchers and their sponsors, and the extravagant predictions of population-wide benefits, the reporter should have made an extra effort to find disinterested sources who could put the news in context.

This would not have been difficult. The article cites an editorial in the same issue of the journal urging cautious interpretation of the results. The reporter could have at least used that editorial or an interview with the writer to inject a balance that was missing from this overly enthusiastic report.

NBC’s Robert Bazell didn't have one skeptical comment in his network news report that - thankfully - reaches fewer people these days because of a decline in network news viewing. He never mentioned the appropriately skeptical, cautious comments in an editorial accompanying the New England Journal of Medicine article - something that is low-hanging fruit for any reporter covering the story.

Viewers of the CBS Early Show got one of the most one-sided reports of all. Anchor Harry Smith asked the doc-of-the day:

"So if I’m one of those people of a certain age who might have high certain other markers, should I be running to my cardiologist today, saying ‘Give me the test for this inflammation so I know that maybe I ought to be on this stuff’?"

And she responded:

(Dr. Suzanne Steinbaum:) Absolutely. If you have any risk factors—high blood pressure, high cholesterol, diabetes—but all of these things are sort of borderline and you’re not taking a statin, really this inflammatory marker, the CRP, might tip the doctor over the edge to give you a statin like Crestor.

Let's all rush in tomorrow. We're healthy but we don't know we're dying. Let's find out what bad shape we're in so that we can all be statin-ized ASAP. Wow. What a job journalism is doing in selling sickness and drugs.

Dr. Nancy Snyderman of NBC News appeared on the Today Show with Matt Lauer last week, profiling a physician-author who has written that the best science does not establish a causal link between childhood vaccines and autism.

Lauer, in a followup question, mis-spoke and called it a "casual" link - not causal. One wonders whether he truly knows what the words mean.

Snyderman talked about how the physician-author, Dr. Paul Offit (author of "Autism's False Prophets"), has received death threats. Snyderman herself said she had been physically ambushed by those who contend that vaccines cause autism.

As Snyderman was wrapping up the segment, Lauer said - in typical anchor throwaway language:
"Controversial subject ..."

Snyderman immediately shot back, "Not controversial subject , Matt. ...It's time for kids to get vaccinated. The science is the science. It's not controversial."

You can see the video here or here.

Kudos to Snyderman for educating her big-bucks anchor colleague live on-the-air.