Myrl Jeffcoat myrlj@jps.net
16 mars, 2005 20:27
Medical Doctors Versus
Spin Doctors: Sorting Through Conflicting
Information
Dec. 28, 2004
By Robert H. Shmerling, M.D.
Beth Israel Deaconess Medical Center
Have you ever noticed that what your doctor says about a
medicine is different from what you hear in advertisements or in the news?
The differences may be subtle, perhaps the choice of words, or something
more
dramatic. In fact, it may seem like one of the sources of
information - whether the media or your doctor - must be wrong. When these
differences arise, it's natural to wonder: If one medicine is clearly best
in the television ads, why is a different course of treatment being
recommended by your doctor? There are several possible explanations, and
sorting them out may be helpful to you in understanding what your doctor
is saying and how to
make better health care choices.
The Facts Seem Simple
For years, I watched advertisements for various remedies and
wondered how the claims they made could be true - after all, we'd been
taught a very different version of the facts in medical school and in
later training. For example, consider pain relievers for "aches and pains"
such as muscle soreness or minor injuries. The nonsteroidal
anti-inflammatory drugs (NSAIDs, including aspirin, naproxen and
ibuprofen) and acetaminophen-containing medicines (such as Tylenol) are
the main players for over-the-counter options. Here are some relevant
facts about them (at least as we know them now):
Effectiveness of the over-the-counter NSAIDs (including the
many formulations of aspirin, Advil, Motrin IB and Alleve) are considered
equivalent; in fact, when comparable doses are taken, even the
prescription forms of NSAIDs are about the same in terms of how well they
work.
The NSAIDs provide pain relief in two ways: by reducing
inflammation, wherever it may be, and by a direct pain-relieving
(analgesic) effect on the brain.
The side-effect profiles of over-the-counter NSAIDs are also
similar to one another, although uncoated aspirin may cause a higher
incidence of stomach problems. For the most part, though, they all have
the same side-effect
profile, with the most common problem being upset stomach and
occasional ulcer disease. They may also worsen kidney failure in people
with pre-existing kidney disease. Older NSAIDs, including those available
over
the counter, thin the blood a bit, which may be a problem for
people with bleeding problems or easy bruising.
Acetaminophen (as in Tylenol and many other products) causes
far fewer (if any) stomach problems, provides similar pain-relieving
effect as NSAIDs for many conditions, but has little or no
anti-inflammatory effect.
NSAIDs and acetaminophen reduce fever; when a fever is present,
some of their benefits are probably related to this effect. However, when
the issue is solely fever reduction, acetaminophen is usually the
preferred choice because it is considered
safer.
The dosing schedule varies between these drugs: Acetaminophen
is taken every four to six hours. Naproxen (as in Alleve) is taken two to
three times a day. Ibuprofen (as in Motrin IB or Advil) is taken up to
four times a day.
The dosing differences do not imply that one is stronger, more
or less effective or more or less risky to take; the differences are
simply a consequence of how they are broken down by the body and,
therefore, how long they last in the body's tissues.
Spinning The Facts
Even if everyone (doctors, patients, drug advertisers, news
media, the FDA and agencies that oversee drug manufacturing, promotion and
truth-in-advertising) agreed on the above facts, "spin" can alter how
these facts are delivered. For example, one or another of the
manufacturers could truthfully make the following claims, each suggesting
that one medicine is superior to its competitors (even when it isn't):
"Nothing is proven stronger."
That's true since they are all about the same in terms of
effectiveness.
"Just one pill provides all the relief you'll need for the
day." That may be true, but that's a matter of convenience for the less
frequently dosed medicines, not "power" or overall
effectiveness.
"I don't care about the studies. I just know it works for me."
Testimonials about one or another pain reliever being the best are readily
available for each and every one of them, so one should never rely too
heavily on them. Remember that the person
making these statements is usually being paid by the drug's
maker.
"When doctors and hospitals choose, more of them prefer this
drug." While this may be true, it's important to note why they are
choosing the medicine; a bit of information that may be left out of the
claim. For example, acetaminophen may be the most commonly prescribed pain
reliever in hospitals, but that may be due to its fever-relieving capacity
that it is prescribed so often. If you are looking for a pain reliever and
you don't have a fever, that claim may mislead you into thinking that
acetaminophen is a better pain reliever.
Consider The Source
A recent analysis of research comparing chiropractic care with
traditional approaches (such as exercise and medications) found no
difference between the two in terms of effectiveness, and both were better
than no treatment. It also demonstrated how spin can alter the message
even while sticking to the facts. News articles interviewing chiropractors
hailed the study as proof that nothing is more effective than spinal
manipulation and that it represents a safe alternative to medications.
Other news reports said the study was a disappointment to the advocates of
chiropractic manipulation because it did not find that such care was
better than other types of care
and may cost more. Some predicted that based on this research,
insurers would be more likely to cover chiropractic care for back pain;
other news articles stated just the opposite.
One finding of the study that was buried in the "spin" was that
neither traditional therapies nor chiropractic care were dramatically
helpful compared with no treatment! With all of this shifting emphasis
depending on the messenger, no wonder the message from your own doctor may
differ from that you happen to read or hear in the
news.
There are many other examples of this phenomenon. If you ask
your doctor about allergy medicines (such as Allegra or Claritin), the
newest anti-inflammatory medications (such as Bextra or Celebrex), or
medicines for heartburn (including Nexium or Prilosec), your doctor may
suggest a different treatment. A nonprescription medication or an older,
generic medicine may work as well at a fraction of the cost. Your doctor
may even suggest no medication for your problem, especially if symptoms
are mild and avoidable. For example, some allergy sufferers can simply
avoid certain plants at particular times of the year and do well without
medicines.
A common situation that I encounter in the office is the
request for a medication that a friend or family member is taking. It's a
logical question - there seem to be no side effects and it's working well
for them, so why not try it? If your doctor is not enthusiastic about the
idea, it may be because your symptoms or illness is quite different from
that of your friend, or your other medical problems and medications may
make that treatment less attractive. In that situation, what your doctor
is saying is this: Each person is different so the risks and benefits of
treatment will differ.
Why Spin?
Although the ideal situation might be objective, scientific
analysis driving every medical decision, the fact is that there is much we
don't know, we all have our biases and are affected by the bias of others.
The undeniable truth is that "reversing spin" is an enormous challenge.
Consider the following reasons that operate to manipulate the health care
message: Bias may not be
conscious. Imagine that your doctor was trained by a world expert in
infectious disease and urged the use of a particular antibiotic for a
common condition. Years later, your doctor may be prescribing that
treatment even if better ones have come along, in part because of the
impression made by his or her mentor. Similarly, a friend or family
member's experience with a medicine or treatment may powerfully affect
your views on it. In both of these examples, the existence of bias may not
be obvious.
Bias may be intentional. Experts in marketing know how to take
a fact and emphasize one aspect, downplay another and present it in a way
that directly influences opinions, decisions and behaviors. Although you
may not always realize it's going on, advertisers and others with a vested
interest in the health care decisions you make with your doctors may
consciously deliver a biased message and that may differ from the one you
hear from your own doctor.
Perspective matters. Your doctor is primarily interested in
your health and well-being while your other sources of information may be
focusing on other issues (news media want readers or viewers; drug
manufacturers want more prescriptions written for the medications they
make; health care maintenance organizations want to promote the quality of
their members' care while also controlling costs, and so on). The
difference in these perspectives will often explain the difference in the
message you read or hear in ads or the news and the one you hear from your
doctor.
Conclusions
When it comes to health care decisions, the facts are important
but so is spin. Simply recognizing that spin is at work is not easy.
Perhaps the best any of us can do is to stay informed, relying as much as
possible on impartial information from sources that are not trying to sell
us something. Read medical writers who seem to look at stories from more
than one side. But recognize that everyone is biased to some degree and
everyone has a perspective that influences his or her outlook. Recognize
that there may be a number of good explanations (and some that aren't so
good) for why the message of news media and advertisements differs so much
from what your doctor is saying. My advice is this: Be skeptical about
what you read or hear and, importantly, consider the
source.
Establish a relationship with a doctor you trust and ask
questions about something you've heard or read, especially if you are
unsure about the reliability of the source. Ask why your prescription is
being changed. Perhaps you would elect to pay a higher price out of pocket
to stay on it, or perhaps you're willing to switch because your insurance
company wants you to, but either way, you'll be better informed if you ask
about it. Academic medical centers and government agencies are often good
sources of information because they do not have "vested interests" likely
to alter the medical message - but that may just be my
bias.
Robert H. Shmerling, M.D., is associate physician at Beth
Israel Deaconess Medical Center and associate professor at Harvard Medical
School. He has been a practicing rheumatologist for over 20 years at Beth
Israel Deaconess Medical Center. He is an active teacher in the Internal
Medicine Residency Program, serving as the Robinson Firm Chief. He is also
a teacher in the Rheumatology Fellowship Program.
