Much virtual ink has been spilled over the United Stated Preventative Services Task Force (USPSTF) breast cancer screening recommendations. Though I’ve written in general terms about the generally underappreciated complexity of screening tests and whether they are the unadulterated good most people think, the specifics of the USPTF recommendations and ensuing controversy have been covered at Science-Based Medicine and by Orac at Respectful Insolence with great detail and insight, so I have not felt motivated to contribute to the discussion surrounding them. However, the aspect of the brouhaha that strikes me as most disturbing and most central to the core issues I deal with here at SkeptVet blog, how to improve the practice of medicine through better use and reliance on science and scientific evidence, have recently been expressed succinctly on the KevinMD Blog. The post is short and to the point, so I will quote it in its entirety with all emphasis being mine:
“The fallout from the mammogram screening guidelines have served as a test case, of sorts, to see how the politicians and public will respond to recommendations based on evidence-based clinical practice.
And, judging from the inflammatory reaction, it’s safe to say that we’re quite a ways from medical decisions based on the best available data.
In a recent editorial, the New York Times touched upon the issue. One of the Senate’s health care bill amendments explicitly mentioned the USPSTF and “directed the government to ignore the task force’s most recent mammography recommendations.”
It overwhelmingly passed.
Health reformers are hoping that results from comparative effectiveness trials can help reduce the amount of practice variation, which is a leading driver of rising health spending.
But whenever the evidence calls for less medicine, the political and public outcry will be deafening. Today it’s mammograms. What if tomorrow an independent body calls for, say, a reduction of angioplasty or cardiac bypass surgery, which studies have suggested are being overused?
Both the politicians and the public will simply cry, “Rationing!” Thus, the myth that more care is better care will continue to be perpetuated, and the data ignored.”
I strive to avoid cynicism in my outlook on the future of science-based medicine, but I have to agree wholeheartedly with these sentiments. Orac has illustrated flaws and errors in the way the recommendations were marketed to the public, but while he may well be right, I think it is beside the point. Fear and a natural risk aversion makes us predisposed to make bad judgments about risk and benefit and to always seek what appears superficially like the safest course even when the data shows it is not the most likely to lead to a good outcome. It is difficult for doctors to do nothing even when that is the right thing to do, and it is even more difficult to convince patients and clients that it is sometimes better not to intervene with a test or treatment. Primum non nocere (First do no harm) is a cliché, but despite the fact we’ve all heard it, we seem constitutionally challenged when it comes to heading it. Hmmm, maybe if we printed it on T-shirts and gave them away to doctors? Seems to work for the pharmaceutical reps. Or perhaps we simply have to give up on the current generation and focus on teaching critical thinking starting in pre-school, inculcating the habit of ignoring one’s own intuition when the data says we should? Any ideas?
I was struck by how many of the comments on the USPSTF guidelines that I heard on the radio and TV news and locally followed the form of “my family has a high incidence of breast cancer and these guidelines are a death sentence!”. Despite the fact that the guidelines specifically said they were for people with average or low risk, not those with higher risks.
Some of that was probably political fear-mongering, but others seemed to be people’s honest feelings about the guidelines, even though they were a gross misinterpretation. Unfortunately the complexity and nuance of these things are very difficult to communicate to many people.