Guidelines: What the media does, doesn’t do—and why

1. Guidelines: What the media does, doesn’t do—and why Sharon Begley Senior Correspondent, Health and Medicine, Reuters Evidence-Based Guidelines Affecting Policy, Practice and Stakeholders New York Academy of Medicine December 11, 2012

2. (Some) DoctorsResist Guidelines The majority of doctors continue to recommend annual cervical screening for women in which guidelines suggest waiting 3 years between negative Pap tests. [Roland et al. American Journal of Obstetrics & Gynecology, 2011] Although guidelines for acute low back pain call for advice and analgesics, 80% of 3,533 patients in a 2010 study were not given advice and 82% were not given analgesics. Many got harmful drugs not recommended in guidelines: 37% got anti-inflammatory drugs, 20% opioids. [Arch Int Med 2010: 170(3)]

3. Guidelines? What guidelines? • Nearly 30% of physicians reported routinely ordering ovarian cancer screening for women at low risk for the disease, despite recommendations against routine screening. • Incidence of ovarian cancer is low, and screening tests have high false-positive rates and low positive predictive values. In addition, there is no proof that screening affects morbidity or mortality rates of ovarian cancer. • [Baldwin LM. Ann Intern Med. 2012; 156: 182-194]

4. Why do doctors resist guidelines? Not because they’re unaware of them. “A growing number of doctors and patients have begun to chafe under the absolute one-size-fits-all view of disease inherent to guidelines. Most guidelines assume the presence of only a single condition or risk factor, recommend unwavering cutoff points for treatment and are based on averages derived from large groups of patients. But real patients are rarely average.’”-- New York Times, May 19, 2011 The US has a pay-for-service healthcare system

5. What the press likes • Personal stories, anecdotes—that is, individuals over statistics • The surprising & unexpected • Controversy • Skepticism/contrarianism

6. Personal (and Contrarian) • Prostate cancer survivor: PSA test 'saved my life' (News 9, Denver, October 8, 2011) • Officer: Colonoscopy saved my life (Jacksonville Action News, March 29, 2012) • Any number of similar quotes, stories and testimonials can be found instantly by searching the internet. The stories usually drive home the message, “get the test,” and are seen by their publishers as essentially Public Service Announcements—regardless of guidelines.

7. Controversy: Sex Sells • The inevitable social controversy over guidelines on “hot” topics like Plan B for teenagers and vaccination for HPV almost guarantees extensive coverage. • Plan B guidelines announced last month generated to 643 news stories, including major newspapers, TV networks, wire services, magazines (Google News search 12/4) • HPV vaccination guidelines received similar wide coverage (644 stories, Google News search 12/4)

8. Unsurprising? Six organizations issue new clinical recommendations in November 2012 for diagnosing and treating stable ischemic heart disease (IHD) • “Patients with chest pain should receive a thorough history and physical examination to assess the probability of stable IHD prior to additional testing. Choices regarding diagnostic and therapeutic options should be made through a process of shared decision making between the patient and physician to discuss the risks, benefits, and costs to the patient.” • These definitely non-shocking guidelines received almost no news coverage. (Google News Search: 3 stories)

9. Watchdogging • The press likes to sniff out potential conflicts of interest and be a “consumer watchdog” • When an interest group takes a position against its perceived own financial interest, the story is likely to get more favorable coverage • “Choosing Wisely”

10. Cervical Cancer Screening • In 2009, the American College of Obstetricians and Gynecologists said get fewer Pap tests (women over 30 who have had three or more normal annual Pap tests can be screened every 3 years instead of annually). •  Extremely favorable and extensive coverage, mostly because a group that would be expected to take a different view (i.e. ACOG should want women to get PAP tests every month) recommended ‘doing less.’

11. Cholesterol • Abundant controversy about cholesterol, including about what level means you should be on a statin and who should be screened • November 2011, a panel assembled by the National Heart, Lung and Blood Institute issued guidelines  calling for universal screening of all 9 to 11-year-olds with a non-fasting lipid panel. Previous recommendations called only for children considered at high risk of elevated levels to be screened with a non-fasting total cholesterol test.

12. Consider the Source • The press follows the ‘consider the source’ doctrine, and if the source has a financial interest in the guideline then coverage is often more skeptical. • The NHLBI panel chair and members disclosed extensive financial relationships with companies making statins and lipid tests, including paid consultancies or advisory board memberships with Merck, Pfizer, Astra Zeneca, Bristol-Myers Squibb, Roche and Sankyo.

13. . . . And consider the evidence • August 2011: A study in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists, found that barely one-third of the group’s clinical guidelines meet the Level A standard of “good and consistent scientific evidence.” The majority of ACOG recommendations for patient care rank at Levels B and C, based on research that relies on “limited or inconsistent evidence” and on “expert opinion.”

14. The Modern Media Environment • 'In the relativistic haze of participatory media, it's all just a matter of opinion. You are entitled to yours and I am entitled to mine. . . . The Internet welcomes everyone into the conversation. An op-ed in the New York Times may as well be a column on the Huffington Post. . . . Everyone's opinion may as well matter as much as everyone else's, resulting in a population who believes its uninformed opinions are as valid as those of experts who have actually studied a particular problem." [Douglas Rushkoff, 'Present Shock'] • 'In this era of exploding media technologies there is no truth except the truth you create for yourself." [Richard Edelman, PR guru]

15. Trusted No More • In part because of this proliferation of sources, the media are not trusted. • In turn, relying on the media to “get the word out” and educate the public and practitioners about medical guidelines may not be the best strategy.

16. Gallup Poll, Sept 21, 2012

17. Key Gallup Findings • “Americans' distrust in the media hit a new high this year, with 60% saying they have little or no trust in the mass media to report the news fully, accurately, and fairly. Distrust is up from the past few years, when Americans were already more negative about the media than they had been in years prior to 2004.” • In the 1970s 72% expressed high trust in the media

18. Gallup Poll, December 2, 2010 Most Americans Take Doctor's Advice Without Second Opinion • Despite the advent of health websites and other widely available sources providing medical research and information, 70% of Americans feel confident in the accuracy of their doctor's advice, and don't feel the need to check for a second opinion or do additional research. Americans' confidence in their doctor is up slightly from eight years ago.

20. Reporters or doctors? • The best strategy is likely to be one that focuses on physicians and other health professionals, not the traditional media