I was struck by the recurring themes in this week's health news and planned to blog about it today. But Lindsey Tanner of AP beat me to it with her story, "Experts say US doctors overtesting, overtreating."

She begins:

"Too much cancer screening, too many heart tests, too many cesarean sections. A spate of recent reports suggest that too many Americans - maybe even President Barack Obama - are being overtreated.

Is it doctors practicing defensive medicine? Or are patients so accustomed to a culture of medical technology that they insist on extensive tests and treatments?

A combination of both is at work, but now new evidence and guidelines are recommending a step back and more thorough doctor-patient conversations about risks and benefits."

I had picked up on that same theme in this week's news:

• An independent panel convened this week by the National Institutes of Health confronted a troubling fact that pregnant women currently have limited access to clinicians and facilities able and willing to offer a trial of labor after previous cesarean delivery.

• A troublingly high number of U.S. patients who are given angiograms to check for heart disease turn out not to have a significant problem, according to the latest study to suggest Americans get an excess of medical tests.

• CT scans may pose cancer risk, new research indicates: Doctors, patients should weigh risks vs. rewards of medical imaging. (Chicago Tribune story.)

• Controversy over "value-based insurance design" that tries to address the problem of underuse of proven treatments and overuse of certain surgeries and diagnostic tests that may be less valuable. (Kaiser Health News story.)

• Expensive prostate cancer treatments are winning out over the old standards, driving up the cost of treatment before there's clear evidence that they improve outcomes. (MedPageToday.com story.)

• Dr. Richard Ablin's op-ed in the New York Times, "The Great Prostate Mistake." Excerpt:

"Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit."

• And the letter to the editor that followed:

To the Editor:

I can only wish that Richard J. Ablin's article had appeared years ago and spared me and probably many others needless pain and anxiety.

In 1997, at the urging of a couple of friends, I walked into a clinic feeling great and a bit foolish. P.S.A., 9-plus. Biopsy, of course (ouch), and I was told of a "little suspicious gray area" on a film. Lab test result, positive. Doctor recommendation: surgery or radiation.
I decided against both and never looked back, and have lived happily and healthfully ever after.

By the way, the 10 or 15 percent chance of bad side effects (I asked) from surgery is really far higher, from what I've read and heard. Watchful waiting is still the best suggestion any doctor can offer.

Robert S. Corya
Indianapolis, March 10, 2010

• CBS' Harry Smith's live colonoscopy coverage that never touched on any questions about evidence for colonoscopy and some of the questions that have been raised about the overselling of colonoscopy - perhaps resulting in the decline in use of a $20 blood stool slide test.

While Smith's colonoscopy was being televised, I was attending a meeting entitled, "First, Do No Harm," hosted by the US Agency for Healthcare Research & Quality. The purpose of the meeting was to guide future AHRQ research on how to get doctors and patients to stop pursuing approaches for which there is net harm - not benefit. Clearly, health care in the US struggles even with the clearcut issues of cutting back in the face of net harm - much less in grey areas where there is uncertainty about harms vs. benefits.

But kudos to Lindsey Tanner of AP for trying to tie together the week's news in the way she did. We could have stories like that every week. And if we did, we'd have a lot smarter health care consumer population.

Dr. Richard Besser reports - as summarized on the ABCNews.com website - "Fosamax, one in a class of drugs called bisphosphonates, is supposed to make bones stronger, and for many women, it is safe and effective. But now there's mounting evidence that, for some women, taking these medications for more than five years could cause spontaneous fractures."

Syracuse reporter James Mulder cracked this story.

As with the Chicago Tribune story cited earlier today, this story ends with a powerhouse quote from one observer:

"You may not think you are being biased, but if you make 10 minor decisions in a row that are all slightly biased, all those little biases add up in the end. It's an unhealthy situation."

Hat tip to Pia Christensen for the tip on this.

Headline: "CT scans may pose cancer risk, new research indicates: Doctors, patients should weigh risks vs. rewards of medical imaging." Good infographics in the paper and online (see below). And a sober ending:

"And some doctors who own scanning equipment have a financial stake in diagnostic imaging. Research shows that doctors who own machines perform two to seven times more imaging tests than those who don't, said Dr. Vijay Rao, chair of radiology at Thomas Jefferson University Hospital in Philadelphia.

Moreover, "the physicians who own this equipment and order the tests have generally had no training in radiology and little understanding of the complexities of radiation dosing" and its attendant health risks, Rao said. "For patients, this is absolutely the perfect storm."

It was just 20 months ago that ABC News called the drug dimebon a "miracle for Alzheimer's Disease."

They weren't alone in singing the drug's praises after a preliminary trial. WebMD proclaimed, "Dimebon Shines as Alzheimer's Therapy."

Yesterday, MedPageToday.com reported, "Novel Alzheimer's Drug Flops." Excerpts of their story:

The investigational Alzheimer's disease drug dimebon failed in the pivotal CONNECTION trial of patients with mild-to-moderate disease, the drug's makers announced today. Latrepirdine did not result in significant gains on any of the five efficacy endpoints versus placebo after six months of treatment, according to Medivation and Pfizer, who have a partnership to develop the drug.
...
Peter Davies, PhD, an Alzheimer's disease expert at Albert Einstein College of Medicine in New York City, said in an e-mail, "I am personally disappointed, but not surprised."

"The results from the (earlier widely reported) study were too good to be true."

There's a reason why words like "miracle...breakthrough...promising...hope" can be troublesome in medical research stories. This is another example.

(My thanks to Andrew Holtz for his inspiration on this post.)

WebMD headline: "Vitamin D linked to lower heart risk."

OR

Reuters headline: "Calcium, Vitamin D pills don't help heart."

Same study. Quite different stories.

Look at how the evidence was analyzed differently.

WebMD:

"Researchers found six studies (five of which involved people on dialysis and one which included the general population) showed a consistent reduction in heart-related deaths among people who took vitamin D supplements. But four studies of initially healthy individuals found no differences in development of heart disease between those who received calcium supplements and those who did not.

A second analysis of eight studies showed a slight, but statistically insignificant 10% reduction in heart disease risk among those who took moderate to high doses of vitamin D supplements."

Reuters:

"Some studies did show that vitamin D supplements cut the risk of dying from heart disease and stroke. However, most of these involved patients with severe kidney disease who were on dialysis, a vast difference from healthy individuals, (the senior author) noted.

The remaining studies failed to show any meaningful benefits of vitamin D, calcium, or a combination of the two."

The WebMD piece seemed to keep trying to make the case for there being some heart benefit from vitamin D when that isn't what the results they presented indicate. No matter how you cut it, the evidence in favor of vitamin D having heart benefit is not robust, so how did they decide on the definitive headline, "Vitamin D linked to lower heart risk"?

The Reuters story helped people understand that more vitamins isn't necessarily better - with the editorial writer's quote, "We've learned in the past that things can go really, really wrong" when people start taking vitamin pills.

What a great idea for a blog - with a focus solely on the practice of embargoes in the management of the flow of health/medical/science news and information.

Reuters Health executive editor Ivan Oransky just launched his Embargo Watch blog last week but already has a faithful following. It's evidence, I think, of what a sore subject embargoes are and have been with so many who have toiled in these fields for so (too?) long.

In his initial post, Oransky wrote:

"You've probably noticed that every major news organization -- including mine, Reuters -- seems to publish stories on particular studies all at once. Embargoes are why.

A lot of journals, using services such as Eurekalert.org, release material to journalists before it's officially published. Reporters agree not to publish anything based on those studies until that date, and in return they get more time to read the studies and obtain comments.

That would seem to be a good thing for science and health journalism, much of which is reliant on journals for news because it's peer-reviewed -- in other words, it's not just a researcher shouting from a mountaintop -- and punctuates the scientific process with "news events."

Vincent Kiernan doesn't agree. In his book, Embargoed Science, Kiernan argues that embargoes make journalists lazy, always chasing that week's big studies. They become addicted to the journal hit, afraid to divert their attention to more original and enterprising reporting because their editors will give them grief for not covering that study everyone else seems to have covered.

But even if embargoes are a necessary evil, they're not uniform, and how each organization deals with them provides case studies in some of the chinks in embargoes' armor."

Ironically (or was this a test case?), Reuters itself lost its advance notice "privileges" from the American Heart Association last week for jumping an embargo by a whopping 43 minutes. (Correction added 12:21 pm Central time, March 1: They jumped the embargo by 1 hour and 43 minutes. A bit more whopping.)

The Embargo Watch blog is a great concept. It becomes a repository for embargo-related issues. It provides a social media platform for all parties involved in the dissemination of health/medical/science (and other) news and information to weigh in on the issue. Who knows? It may even lead to a better system.

We've written before about some of the headlines praising robotic surgery:

• Robot doctor - surgery of tomorrow

• Da Vinci puts magical touch on the prostate

• Cancer survivors meet lifesaving surgical robot

• Robotic surgeon's hands never tremble

• Da Vinci is code for faster recovery

• Surgical Maestro

• DA VINCI ROBOT IS SURGERY WORK OF ART

Now even the news that a company is testing a couple of robotic-surgery-training-simulators "and expects the units to go on sale for about $100,000 by early 2011" makes news.

The AP reported it (this is their photo at left of the news conference) and the story was picked up by ABC News.com, CNBC, the Los Angeles Times and elsewhere.

Granted, a simulator that might help train docs in what seems to be the inevitable spread of this technology might be an important quality/safety improvement.

But the AP story that spread across the country didn't mention any concerns about the medical arms race involving robotic devices, nor any questions about evidence.

• Hold news conference.

• Demonstrate gizmo.

• Get nationwide news.

How easy it can be to get free publicity, without ever having people focus on some of the important policy questions at stake. But after this week, who cares about health care policy, anyway?

There's now a website that actually tracks The Daily Mail of London to categorize its stories as either "kill or cure" stories. The site quotes British physician-author Ben Goldacre: "The Daily Mail, as you know, is engaged in a philosophical project of mythic proportions: for many years now it has diligently been sifting through all the inanimate objects in the world, soberly dividing them into the ones which either cause - or cure - cancer."

Visitors to the site can vote on the stories.

So far, the following things cause cancer: age, air pollution, air travel, aluminum, artificial flavors, artificial light.... You get the picture. That's only in the A alphabetical listing.

So far, the following things prevent cancer: bananas, Brazil nuts, breakfast, etc. Beer, it should be noted, both causes and prevents cancer!

Hmmm. I may have just received inspiration for a new health news review project in this country!

Australian journalist Melissa Sweet writes in the BMJ this week (subscription req'd for full access) about "Science, politics, and headlines in the home birth war," regarding a recent study published in the Medical Journal of Australia

She raises questions about journal editorial practices, journal news release practices, and news coverage that relies on those news releases. (Disclosure: she interviewed me for the BMJ article.) Excerpt:

"Last month the Medical Journal of Australia published a study on outcomes of home birth that generated many media stories sounding the alarm about the safety of such births.

Many stories focused on the study's findings that babies were seven times more likely to die during labour in a planned home birth and in particular were 27 times more likely to die from asphyxiation."

Some also did mention the finding that there was no significant difference in the overall perinatal mortality rate between planned home births and those planned for hospital delivery.

These were also all findings highlighted in the media release accompanying the journal, which made no mention of uncertainty surrounding the relative risk estimates. The confidence interval for both was wide: 1.53 to 35.87 for intrapartum deaths and 8.02 to 88.83 for deaths from intrapartum asphyxia.

Other questions she raises:

• the journal news release didn't mention the numbers of deaths involved or the absolute risks.

• "Nor did it mention the authors' caveats that 'small numbers with large confidence intervals limit interpretation of these data" and that 'in the 16 year study period there were only three perinatal deaths for which one can reasonably assume that a different choice of care provider, location of birth, or timing of transfer to hospital might have made a difference to the outcome.' "

• the news release quotes an obstetrician who is president of the Australian Medical Association and who wrote the accompanying editorial. The association, Sweet reminds readers, "which owns the Medical Journal of Australia, opposes home births and has been at loggerheads with nurisng and midwifery organizations over propoed reforms of maternity services in Australia."

• One homebirth advocate said that most of the journalists who interviewed her "said they had not read or even sourced the study."

Sweet has also written about this in more detail on the Croakey health blog.

If you're interested, here are links to related materials:

• The study on homebirth outcomes.

• The journal news release.

• Other posts on the Croakey blog about this issue.

Why is this worth the attention? Because it's a case where research - and how it's published and intepreted - could affect public health policy. It happens all the time. We just don't often see it broken down as well as Sweet did in this case.

A UK parliamentary panel this week recommended against public funding of homeopathy, as Susan Perry of MinnPost.com wrote.

"[E]xplanations for why homeopathy would work are scientifically implausible," the panel said.

She cited one estimate that Americans spend $830 million on homeopathic products each year.

Meantime, British physician and writer Ben Goldacre wrote that the BBC had hit rock bottom by giving more than five minutes of airtime to a woman who claimed her cancer was cured by homeopathy. Here's the clip:

For a bit of background, go to this link to see an interesting video featuring BBC health correspondent Branwen Jeffreys explaining homeopathy.

Some websites, predictably, have pulled out the following BBC comedy spoof of homeopathy.

WBBM in Chicago last week asked, "Is Medicare Ignoring Cheaper Lung Cancer Test?"

In its report, the TV station's "investigator" team promoted a company president's complaints against Medicare for much of the piece. They let him get away with saying:

"This is a potentially very powerful tool in the toolbox against lung cancer. You can zap the cancer and potentially be cured of early-stage lung cancer without ever having the surgery."

Should we be hearing that from a company president worried about his bottom line while he "wows" the audience with blown-up images like the one at left that appeared in the story? Or should we hear about evidence and data from an independent investigator whose research could speak to efficacy? The story never provided any data to back up the company president's self-interested claims.

They also let him get away with saying, "I think it has the potential to save Medicare millions of dollars."

We're not getting much smarter from stories like this. We're sure not getting a better understanding that in health care, "more is not always better and newer is not always better." We're also not being shown how often special interests - Pharma, device makers, specialty physician groups, etc. - are digging in against health care reform.

Recently, Trudy Lieberman wrote in the Columbia Journalism Review about how cardiologists were using journalists to complain about their reimbursement levels being cut by Medicare. She wrote:

"The doctors' letter warned that they "will be either forced out of business or forced to drastically increase the number of patients seen, most likely with physician assistants or nurse practitioners." Oh, oh. The specter of rationing and inferior care--"

See the similar themes in what she wrote about and in what we saw in the Chicago WBBM story?

Lieberman praised a Miami Herald story for how it handled the issue but said that:

"..a bunch of news articles for the most part passed along the cardiologists' complaints, threats, and warnings without any hint that there was another side to the story. Between the slanted newspaper articles and audio news releases from the American College of Cardiology, millions of Americans learned that the incomes of heart doctors, which can be upwards of $400,000, could take a hit. As an example of the kinds of cuts Medicare envisioned under the new rule, the administrator of one Florida heart practice explained that the reimbursement for a nuclear stress test could drop from $850 to $600. Presumably he said it with a straight face."

News stories that foster rhetoric and fear-mongering aren't making us any smarter. As Lieberman wrote:

"Containing the runaway cost of medical care is the thorniest of all the thorny issues in the health-reform debate. It is a complicated, charged, and crucial issue; the press needs to dig in and own it."

This is the second business section health news story we've questioned today. But we're not the only ones.

A Star Tribune headline screamed, "Blockage Breakthrough" on behalf of a local company's hopes for its coronary artery intervention product.

Problem: We never learn what the product really is or how it works.

We only hear the praise from one - just one happy patient - and the pronouncement from the lead investigator (perhaps a bit conflicted?) that this is the closest they can come to the Holy Grail for treating blocked coronary arteries.

Readers are not dumb. Online, some commented as follows:

• "I don't get it...exactly what is the breakthrough? It sounds like a normal angioplasty,"

• "Please define what (these devices) actually do."

• "There is no description of what it is, what it does."

• "Seems like the main point is not in the article? So how does the thing work? I kept reading it over thinking I missed it in there."

No matter where you live - think twice about health stories on the business page that make things sound too good to be true. And if the story doesn't deliver what you need to understand, take a moment to write in as these folks did. Maybe someone will listen.

Usually when something Texan tries to move into Oklahoma, there's a great deal of skepticism. But that's on the sports page.

On the business page of The Oklahoman, a recent health news story was treated like free advertising for a Texas company now bringing its mobile health screening services to Oklahoma. Excerpts:

Austin-based HealthYes! uses the latest equipment and techniques to screen for heart disease, stroke, abdominal aortic aneurysm, peripheral artery disease, diabetes, liver disease and osteoporosis,(said the company president).

"Our goal is to educate people to take a proactive approach to their health care," he said. "So many people don't get these tests because they have no symptoms."

HealthYes! fills a niche in the preventive-care arena, he said. "There's a real need out there."

Another classic example of a business section failing to exercise any tough journalism on a health news story - and of a news organization failing to realize that there can be harms from screening that is done outside the boundaries of evidence.

The story only quoted the company president - who, of course, sees a "real need" and a "niche."

But there isn't one quote with a doctor who could raise questions about what evidence there is to support population-wide, drive-around-screening offerings for "heart disease, stroke, abdominal aortic aneurysm, peripheral artery disease, liver disease and osteoporosis."

If you're scoring at home:

Free advertising 1, Journalism 0

Or

Business Interests 1, Consumers 0

Another entry in our "Question Mark TV Health News Hall of Shame." Drum roll please.

Today's CBS Early Show had a segment on a study showing a statistical association between ibuprofen use and reduced risk of Parkinson's Disease.

Anchor Maggie Rodriquez introduced Dr. Jennifer Ashton by saying: "So I guess this is the magic pill."

Ashton responded, "Well it appears that way."

Well, no it doesn't. Not yet at least.

Meantime, this graphic appeared on the screen, "The New Wonder Drug?"

To her credit, Ashton tried very hard throughout the rest of the segment to be cautious, saying, "Sounds good but it is an early preliminary finding. ... It was really just an associative finding so it means they didn't explain the cause and effect or the mechanism here. But they just found that those who took ibuprofen at that frequency had a lower risk. So potentially interesting."

Nonetheless, on TV, the pictures and the graphics often overwhelm the message.

And today's "Wonder Drug?" graphic deserves its Hall of Shame status.

CBS' Dr. Jon LaPook covered the report on the nation's health, delivered yesterday by the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. LaPook did a good job driving home the point that more drugs, more imaging, more technology does not necessarily lead to better health outcomes. Two key lines from his story:

"Throwing money at pills and procedures can't buy good health."

"To help patients get their money's worth, doctors need to clearly explain the pros and cons of everything they suggest. And that includes helping then understand that sometimes the best option is ... nothing at all."

I'm also late in applauding Katie Couric's reports last week on feeding antibiotics to farm animals and questions about how that practice is spawning new drug-resistant bacteria.

There's undoubtedly going to be a lot of miscommunication about the latest analysis coming out of the Nurses Health Study, which looks at the impact of different lifestyle factors on women's health.

This time they tracked aspirin use, and then saw how many women were diagnosed with breast cancer. That's an observational study - not a trial - and it can't prove cause and effect.

The analysis showed that women who regularly took aspirin had fewer diagnoses of breast cancer.

What you can say is that this was a strong statistical association in a big study. But you can't say it established a benefit because such a study can't prove cause-and- effect.

Now here comes the NBC Nightly News - from Vancouver for the Olympics - with the water and the mountains in the background. And, rather than a carefully scripted videotape piece, we get live chatter between anchor Brian Willams and NBC chief medical editor Dr. Nancy Snyderman. Excerpts:

Brian Williams: "What is the benefit shown here?"

Snyderman should have stopped him right there. Benefit? As we've said, you can't establish benefits from a study that can't prove cause-and-effect. Sorry, but the language is important. See our primer on this topic.

In her answer, Snyderman briefly said, "They didn't look at cause-and-effect..." but that's awkward. It takes seconds to say, "They followed women who took aspirin and then saw how many got breast cancer. That doesn't prove anything, but it does show a strong statistical link that will lead to more study in this area." This is one of the pitfalls of trying to explain research in a live shot. She had a lot to say and she was live. She didn't quite get there.

Williams continued: "That sounds almost anecdotal. What do we really know?"

Snyderman: "Well it's not anecdotal but it is observational."

Huh? Again, I know she tried, but that's just jargon to viewers watching her with the water and the mountains in the background. She never explained what observational meant, or what the limitations of an observational study are.

Snyderman: "So here's what I think you can say. There's no proof that taking aspirin prevents breast cancer. But if you've been diagnosed and you're on aspirin for another reason, it may be one extra benefit and, frankly, a reason to sleep a little better at night. ..So right now if you're on aspirin, and you're tolerating it and you've had a diagnosis of breast cancer, this is good news."

Look at the cumulative language of this NBC story: "no proof that taking aspirin prevents breast cancer" but then again "benefit...reason to sleep a little better at night...this is good news."

I don't think you can say that at this point after an observational study.

Again, maybe this is one that should have been carefully scripted and pre-taped - rather than another NBC piece trying to capitalize on the beauty of Vancouver in the background for a live shot.

Visit msnbc.com for breaking news, world news, and news about the economy

For a better example of how to handle such a story, look at how Liz Szabo covered the caveats in her USA Today story:

"A study in August also found that aspirin offered a potential benefit against colon cancer.

Yet neither study proves that aspirin keeps cancers in check, Holmes says. That's because doctors in each study merely followed patients for several years, noting which patients developed cancer and, of those, which took aspirin. So it's possible that something other than aspirin controlled their tumors, Holmes says.

For proof, doctors would need to conduct a "gold standard" trial in which doctors randomly assign one group of patients to take a aspirin, then compare their progress with patients randomly assigned to a placebo, says Eric Jacobs, a scientist at the American Cancer Society."

Gina Kolata's NYT piece, "Results Unproven, Robotic Surgery Wins Converts," looks at how "robot-assisted prostate surgery has grown at a nearly unprecedented rate."

Excerpts from the story:

• "..robot-assisted prostate surgery costs more -- about $1,500 to $2,000 more per patient. And it is not clear whether its outcomes are better, worse or the same."

• "Meanwhile, marketing has moved into the breach, with hospitals and surgeons advertising their services with claims that make critics raise their eyebrows."

• "Medical researchers say the robot situation is emblematic of a more general issue. New technology has sometimes led to big advances, which can justify extra costs. But often, technology spreads long before investigators know whether it is worthwhile."

• "...a situation like robot-assisted surgery illustrates how patients may end up making what can be life-changing decisions based on little more than assertive marketing or the personal prejudices of their surgeon.

"There is no question there is a lot of marketing hype," said Dr. Gerald L. Andriole Jr., chief of urologic surgery at Washington University. Dr. Andriole does laparoscopic prostate surgery, and although he tried the robot, he went back to the old ways.

"I just think that in this particular instance, with this particular robot," he said, "there hasn't been a quantum leap in anything."

Start with a paper on Focused Microwave Thermotherapy posted online by a medical journal on December 22 - ahead of print publication.

Follow with a company news release on January 12.

Then a University of Oklahoma Health Sciences Center news release on January 15.

That same day, the Tulsa World published a story under the headline, "Breast cancer treatment pioneered at OU could reduce need for mastectomies," including the projection that "The therapy could be in widespread use in five to 10 years."

The Oklahoman of Oklahoma City published a story on January 16, with one of the authors saying, "This therapy is a major advancement for women with later-stage breast cancer. Right now most patients with large tumors lose their breast. With this treatment, along with chemotherapy, we were able to kill the cancer and save the breast tissue." This same quote - word for word - appears in the University's news release.

Both of these stories said the technique uses a modified version of Star Wars defense system technology - language straight out of the University news release.

The story spread to the Dallas Morning News, the Associated Press, several TV stations and elsewhere - all detailed in this news release from the company about all the news coverage it's receiving!

That news release says that the company "is planning to initiate a Phase III study which hopes to fully demonstrate the safety and effectiveness of our focused heat treatment in order for us to be able to commercialize the technology."

From the sounds of these stories, you might think that proof of safety and effectiveness is already in.

I asked Karen Sepucha, PhD, one of our expert editors on HealthNewsReview.org, to look at the journal article. She raises several questions:

• the significant (~20 percent) number of patients excluded from the analysis;
• couldn't show a positive impact for small or moderate-sized tumors;
• small study (n=28) of patients with large tumors
• it appears that 73% who got microwave actually had breast conserving surgery compared with 93% in the group that got chemotherapy alone. So actually, there are not more patients having breast conserving surgery with the microwave approach;
• a complete lack of data on whether local recurrence is different or whether there are other long term complications (e.g. reading future mammograms, cosmetic result of surgery, pain, etc).

Maybe there are good answers for these questions about the study. But the answers don't appear in the news stories we saw, because the questions were probably never asked.

Do you see why we push for better scrutiny of studies of new technology? Star Wars quotes from news releases isn't enough.

Thanks to the journalist who brought this string of events to our attention.

We've just posted a new guide on the importance of the language used to describe the results of observational studies. Day after day we see stories that use active powerful verbs like "prevent...boost...lower your risk...may cut death rate" to describe the results of these studies. That's misleading and inaccurate because such studies can't prove cause-and-effect. Read more about why in this detailed, thoughtful piece by Mark Zweig, MD, and Emily DeVoto, PhD. (It's actually a revision of a piece these two wrote for us two years ago. The new one fits nicely in our "Tips for Understanding Studies" section.)

NOMINATED FOR '09 BEST MEDICAL BLOG

Last week the website reported that the FDA approved a drug for claw hand - a painful condition that causes bent fingers. That was the news of the day. But ABCNews.com only briefly discussed claw hand before catapulting into a non-stop promotion of possible off-label use of the drug for Peyronie's Disease - a condition in which the penis becomes painfully bent.

Look at how ABC framed this:

The headline is hype. It's not a penis-straightening drug in the eyes of the FDA. It hasn't been submitted for approval for that use.

And is that really an appropriate stock photo to use for this story?

But this story repeatedly promotes off-label use - something the drug company would get in trouble for if they had done it. What was the company's role in this story? The story says the drug company "says that - as a safety precaution - it will do everything it can to discourage off-label use." Yet, the drug company PR guy is quoted citing specific data on alleged effectiveness of the drug for Peyronie's Disease. And the story ends, "If all goes well, (the drug company) says they hope to have the drug approved for Peyronie's within two years."

Hmmm. That makes the Peyronie's benefits of the drug sound pretty good and pretty certain.

And let's count the ways the story promoted off-label use with these excerpts:

1. "may serve as double-duty as a penis-straightener"
2. "The release of the drug this spring may lead to off-label use for Peyronie's Disease."
3. "urologists and patients will find frustrating" any company attempt to discourage off-label use.
4. "...there is great demand for any drug that could be shown to work (for Peyronie's). Xiaflex may be that drug."
5. "Peyronie's sufferers may be 'very motivated' to take risks, especially since few other treatments work."
6. "I'm sure there will be pressure [on urologists] to use it off-label...they have a cohort of patients waiting." (urologist's quote)

Only deep in the story - 665 words deep in a 795 word story - after all of this off-label promotion took place - was there specific discussion of the safety concerns that could burst this balloon. Excerpt:

"It is an invasive procedure with potential bad side effects [such as] impotence [or] penile fracture. I don't think too many urologists will do off-label use until FDA approval for use in Peyronie's Disease," (a UCSF urologist) says.

Bruising, pain, and swelling at the injection site has also been reported in clinical trials of Xiaflex.

And even this came after a bold heading, "Relief Will Have To Wait."

Why would ANYone report on a drug study that has yet to be completed, has not been subjected to peer review and is for an off label use?

Because ABC could put "penis-straightening" in the headline and draw more traffic?

Well, the NBC Today Show's "Inside the O.R." series this week has certainly generated blogger criticism. Earlier we posted Larry Husten's scathing review of the segment on atrial fib ablation. Now Amy Romano on the
Science & Sensibility blog has written about her concerns about the live cesarean section delivery that was part of the series.

NBC execs will probably write off this criticism as coming from a bunch of nobodys - myself included in that bunch of nobodys - but perhaps the suits should pay some attention to the wisdom of the crowds on such matters.

The health spendings projection article in Health Affairs contains this one historic note:

In 2009 the health share of gross domestic product (GDP) is expected to have increased 1.1 percentage points to 17.3 percent--the largest single-year increase since 1960.

A Los Angeles Times story gets to the heart of the matter:

"There is growing concern that as much as a third of the medical care delivered in this country does not help patients.

"Are we getting value for the dollar? That is the question," said Len Nichols, health policy director at the centrist New America Foundation. "If you believe that so much medical care is unnecessary, as I do, then it is criminal that we are spending so much."

Yet there is gridlock on federal health care reform legislation. Indeed, for all the rhetoric and fear-mongering about "government taking over health care," the latest data shows we're already there.

The Wall Street Journal reports and provides this graphic:

"For the first time, government programs next year will account for more than half of all U.S. health-care spending, federal actuaries predict, as the weak economy sends more people into Medicaid and slows growth of private insurance."

One of the reasons we review news stories about "new stuff" in health care is that we believe news stories may drive up undue demand for unproven, perhaps unsafe, and costly new technologies without giving a balanced picture of the tradeoffs between harms and benefits, without evaluating the quality of evidence behind the new ideas, without looking at conflicts of interest in those promoting the new ideas, etc.

At last check, 70% of the nearly 1,000 stories we've reviewed fail to adequately discuss costs, or quantify harms or benefits. A kid-in-the-candy-store view of US health care.

We believe these are health care reform stories - even though they often aren't presented that way. Just look at what we've written about just in the past week and you see the daily drumbeat of news stories and ads that fill our heads with visions of sugar plums in health care.

• CT and MRI scans

• Robotic surgery

• A weeklong network TV series taking you inside the O.R. for technological wonders

• Misleading drug ads

17.3% of the GDP and rising.

Journalists have much to learn in the wake of the Lancet's retraction of a study it published 12 years ago making the case that autism could be caused by vaccines. The Wall Street Journal wrote:

"The journal finally issued a full retraction of a study it ran in 1998 linking measles-mumps-rubella vaccines to autism. The paper, with Dr. Andrew Wakefield as lead author, sent British parents fleeing from inoculations and fed U.S. alarm over preservatives in vaccines.

Even in 1998, overwhelming scientific evidence showed vaccines to be safe. Yet the press-savvy Dr. Wakefield had been getting headlines for his research, and the Lancet's publication fed the controversy by giving him an aura of respectability."

And here's the CBS piece on the retraction:

Lessons for journalists and for the public:

• Publication in a peer-reviewed medical journal does NOT mean that the science is sound or that the finding is gospel truth.

• As the WSJ wrote, "The Lancet episode shows how even reputable publications can become conduits for junk science when political causes run hot. Especially amid the scandal over politically motivated climate science, the public needs professional journals to be scrupulous about their standards and honest about the science."

• Journalists must learn to scrutinize evidence. They must see that the weight of evidence means something.

• Journalists and the public must learn from this example how much harm can be done by premature and imbalanced coverage of scientific claims.

• Finally, a good news story about journalism. Gutsy investigative journalism can make a difference. Some journalists - most notably Brian Deer - did the digging that exposed Wakefield and his flawed claims.

Ounce for ounce, vitamin D may be the most covered (over-covered?) health news topic in American news media.

Look at what we've seen just within the past week.

A New York Times column, "The Miracle of Vitamin D: Sound Science or Hype?" Excerpts:

"Imagine a treatment that could build bones, strengthen the immune system and lower the risks of illnesses like diabetes, heart and kidney disease, high blood pressure and cancer.

Some research suggests that such a wonder treatment already exists. It's vitamin D, a nutrient that the body makes from sunlight and that is also found in fish and fortified milk.
...
But don't start gobbling down vitamin D supplements just yet. The excitement about their health potential is still far ahead of the science."

The Dallas Morning News had a headline, "Heart health: Is vitamin D the new superhero?"

And the Los Angeles Times blog proposed in its headline, "Let's put Vitamin D in the water."

These stories have become - and believe me, we've seen enough to back this up - formulaic and predictable. Headlines that scream MIRACLE...SUPERHERO. Followed by some caveats.

Most of what we've commented on before were network TV news stories including some that committed fear-mongering and disease-mongering.

But this week's examples all came from newspapers. Is it in the water?

The NBC Today Show is traveling around the country this week taking viewers "inside the operating room" to see various procedures.

Monday it was Cleveland and a heart arrhythmia procedure. Very high tech stuff.

Tuesday it was Boston and a baby born by C-section. Absolutely no news. Just drama and cute fat baby video.

An "Inside the Operating Room" series, of course, is going to make surgery and high-tech interventions seem dramatic.

I only wish we'd see a week-long series on primary care - doctors and nurse practitioners and RNs and others dealing with patients in shared decision-making encounters. Last week, at the Foundation for Informed Medical Decision Making's annual research and policy forum, I talked with two health care consumers who truly exemplified the ideal of informed and shared decision-making. Mary Bianchi of Northern California talked about her breast cancer decision-making and Larry Forsberg of Minnesota talked about his BPH decision-making. I wish more Americans could hear more often (in news stories and elsewhere) from smart, informed patients and consumers like these two.

They may not involve high-tech interventions, but primary care encounters are where a lot of the rubber-meets-the-road health care happens - and where true health care reform might take place.

I'm not holding my breath to see that weeklong TV series, though.

Walt Bogdanich and a team of reporters produced a powerful package entitled, "Radiation Offers New Cures, and Ways to Do Harm."

He profiled two people who died - one who received seven times his prescribed dose and one who absorbed "27 days of radiation overdoses, each three times the prescribed amount." But the story also was built on months of research and examination of thousands of pages of public and private records and dozens of interviews.

What makes this so important is that, as the story explains, Americans receive far more medical radiation than ever before. And some of it comes from technologies about which there is tremendous professional enthusiasm - such as IMRT or intensity-modulated radiation therapy. "Without a doubt," the story states, "radiation saves countless lives and serious accidents are rare. But patients often know little about the harm that can result when safety rules are violated and ever more powerful and technologically complex machines go awry."

I'm not going to post more excerpts here because you should read the entire piece and note the other elements of this rich multimedia package - video, interactive graphics, photos, and information graphics.

Powerful, tragic, important. Terrific journalism.

I've created a "Question Mark TV Health News Hall of Shame" for all of those health stories that are teased, introduced or use graphics with a question mark at the end of a sensational claim. I'm going to keep adding to this list, hoping to reach the tease-writers of tomorrow if today's boffo writers won't change. So far we have:

ABC Good Morning America's: "Can Your Purse Make You Sick? Beware 'bag-teria' "

Ivanhoe Newswire's: "Pomegranates Prevent Breast Cancer?"

ABC World News Tonight's: "Fountain of Youth?"

And now CBS Evening News': "Is Salt Deadly?"

The NPR program "On the Media" did a terrific job turning to several sources (including me) for analysis of the journalism ethics issues involved in TV network MD-reporters becoming part of the story while delivering care in Haiti.

Host Bob Garfield used these phrases and terms in describing the reporting in question:

• Gimmick
• Obscures and trivializes the news
• Obliterates any measure of objectivity
• Exploiting patients

You can listen to the entire segment here:

His ending:

"Or maybe the prime canon of medicine just needs an update: Do no harm. But first, roll the tape."

It is surprising how much momentum this discussion gathered as the week wore on. Last night there was an explosion of activity on Twitter after CUNY prof and interactive media expert Jeff Jarvis posted a heated and simplistic series of rants against the Society of Professional Journalists, which had issued a statement urging Haiti reporters to remove themselves from their stories. Blogger Tyler Dukes captured Jarvis' tirade and described it as "hyperbole and distortion," continuing: "These are not the tools of a responsible journalist, but of a blowhard with an axe to grind."

The CBC radio program "As It Happens" began its discussion of this issue with this introduction:

"It is a dramatic image: a reporter who is also a qualified medical doctor springing into action to perform first aid on someone hurt in the Haiti earthquake -- and in some cases, going as far as to perform surgery. All of it during a news report.

And while a physician correspondent giving medical assistance to those injured in a natural disaster is commendable, it does raise some ethical issues about the role of journalists."

They then interviewed me for more than 8 minutes. You can listen to it by downloading this file.

There have been countless articles on this topic this week - many missing the journalism ethics point that many concerned journalists have raised. As I have consistently tried to point out, an ethical middle ground would appear to be this: Physician-reporters should render care if they are so moved but they should not report on themselves doing so.

Broadcasting & Cable is an industry magazine. On their website appeared these comments from TV network executives:

"Steve Capus, president of NBC News, expressed outrage that ethicists would question the judgment of medical reporters who have a unique capacity to help in the face of so much human suffering.

"I'd love for (Poynter Institute Journalism Values Scholar & DePauw University Professor) Bob Steele to have to pick up the phone and [lecture] Nancy Snyderman on the journalistic ethics of driving past a kid who can't walk anymore because he has a crushed leg," says Capus.

"Where would you draw the line? How does one remain absolutely 100 percent objective and say, I'm not going to go near that child who can't walk any further? You don't need to be objective about human suffering. If someone is trained as a medical doctor and they help, good for them. That's the right thing to do."

Frankly, I'd love to hear Bob Steele (who has been quoted this week with concerns about what he's seen) do that as well. But, first, he wouldn't "lecture" in the heavy-handed manner that Capus' quote suggests. He would guide Snyderman through the complex decision-making about exactly the questions Capus raises about where to draw the line and how one alternative path is to simply provide care without promoting yourself and your network in the process. This is something that Steele has done with hundreds of journalists in past years.

The online B&C quotes continued:

Paul Friedman, executive VP at CBS News, says news executives asked themselves all the right questions before letting their medical correspondents practice participatory journalism.

"We always need to ask ourselves is a reporters involvement in the story appropriate and does it in any way impinge on accuracy, fairness and so on," he says. "I just think in this case it is so innocent and the benefit is so obvious to the people who are in need of care that it's not a difficult call to make."

(CBS' Dr. Jennifer) Ashton told CBS News executives that she wanted to go to Haiti first as a doctor. And the network has followed her as she has become a participant in medical efforts there.

"We've felt a little bit guilty about taking her away, for even short periods of time, from what she was doing that was really important compared with reporting," adds Friedman.

Indeed, that's one of the points I made in my CBC interview and one that another journalist made earlier on this blog, when he wrote:

"How do they justify leaving the scene to go do their live shot or writing or other tasks? Does the urgent need magically disappear when the show open rolls?

Just think how many more people these physicians could help if they took a leave of absence from their network jobs in order to provide care full-time... and left the reporting to journalists."

If you haven't had your fill, there wlll be more radio discussion on these issues this weekend on the NPR program, "On the Media," whose hosts also interviewed me.