FORCES INFLUENCING RESEARCHERS
Finally, there is one more part of the culture of medicine with which you should be familiar: the world of medical researchers. Because many medical researchers are also doctors, you may think of it as a subculture. But researchers are subject to some unique forces. Research also strongly influences the information you receive, both in media and from doctors. It is therefore important to know something about how medical research works.
The first thing to know is that research is far from a wholly objective enterprise. Distortions can occur at any stage, ranging from blatant fabrication of data (rare but known ), to convenient dismissal of data that do not agree with our beliefs (much more common), to the unintentional biases that creep in as we design our studies (undoubtedly a daily occurrence).
The second thing to know is that all researchers are curious about gaining attention. Traditionally, this has meant publishing in the scientific literature (following the familiar academic dictum "Publish or perish"). Increasingly, however, researchers have garnered attention via the popular media. Professional and public recognition is often a strong motivating force for us as we seek to present our findings.
The final thing to know is that our publishing venues have interests of their own. The popular media are curious about good, simple stories; "medical breakthroughs" are both compelling and easy to explain. The scientific journals, interested in increasing their own profile in the media, typically send news releases to the media, leading to their articles being covered in popular magazines and newspapers.
Even the universities and hospitals we work for, wanting good publicity themselves, may publicize or advertise the work of their researchers. Here the focus is on new and flashy technologies not widely available elsewhere. Many of these groups are relatively uninterested in research that shows that some new test or treatment is no better than an old one.
You can guess the end result of these forces. Researchers get strongly vested in a particular test or treatment. (Some even have their salaries supported by manufacturers.) Research findings may be selectively reported: findings suggesting benefit are exaggerated, while those suggesting no benefit or worse, harm are minimized or not reported at all. The result is that most of what you hear in health news concerns only what is allegedly new and better.
I don't mean to suggest that all medical research is falsified or that most researchers are dishonest. There is a lot of good research and many good researchers out there. But in general, it is legitimate to say that medical research is biased and only new tests and treatments and that the findings of this work are frequently exaggerated. For you, which means that a certain amount of skepticism is always in order when evaluating medical news.
To be sure, some researchers, not tied to industry, seriously try to analyze what works and what doesn't in medicine. When the utility of a new test or treatment is ambiguous or the data weak, they make every effort to let practicing physicians know. When it comes to cancer screening, however, the opposing forces they face may be overwhelming.
Consider what happened in 1997 when the National Cancer Institute (NCI) tried to evaluate using mammography for women aged 40 to 50. The director of the NCI convened a 13-member panel of impartial medical experts and consumer advocates and asked them to review all the data available on the subject. The goal was to provide some consensus recommendations for American women. Here is the time-honored approach to difficult questions used by all the National Institutes of Health (of which the NCI is one); more than a hundred of these consensus panels have been assembled previously.
The panel concluded that the evidence supporting mammography in this age group was weak. If it did save lives which was far from clear to start with very few would benefit: less than one per 1,000 women screened for an entire decade. And there were clearly downsides: roughly a third of women would have at least one false positive exam, and a substantial number would be told they had cancer, and would be treated for cancer, when in fact they had pseudodisease, a cancer that would never cause symptoms. All in all, the advantages of mammography were simply too close to call. So the panel came to the only reasonable conclusion possible: rather than issuing a yea or nay proclamation, they suggested that individual women should make their own choice.
The reaction to the panel's conclusion was anything but reasonable, and the behavior of a number of prominent academic physicians was decidedly unscholarly. Despite obvious self-interest, radiologists went straight to the news media:10 one suggested the panel was condemning American women to death, another called the report fraudulent.
Bernadine Healy, the former head of the National Institutes of Health and a prominent supporter of women's health issues, stated that she was "very disturbed that a group of so-called experts challenged the notion of early detection" even as she acknowledged that she had not read the report. The director of the NCI said he was "shocked" by the outcome, leading many to wonder why he convened the panel if he already knew there was a "right answer."
The politicians didn't behave much better. Senator Arlen Specter (RPa.) summoned the panel's chairman to defend the recommendation at a special hearing of the Senate Subcommittee on Labor, Health and Human Services, and Education Appropriations. The Senate went on to vote for a nonbinding resolution supporting mammography for women in their 40s. No one thought about being on the wrong side of this issue: the vote was 98 to .
The director of the NCI, now under considerable political pressure, asked his advisory board (a board established to advise the director on NCI policy) to review the panel's recommendation. At first they declined, not wanting to interfere with the time-honored process, but eventually they voted 17 to 1 and only recommending mammography to all women in their 40s.
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