Guest Blog: What Does it Mean if Primary Care Doctors Get the Answers Wrong About Screening Stats?

Elaine Schattner | March 22, 2012

Recently the Annals of Internal Med'­icine pub'­lished a' new report on how doctors (don't) under'­stand cancer screening stats. This unusual paper reveals that some primary care physi'­cians ' a' majority of those who com'­pleted a' survey ' don't really get the numbers on cancer inci'­dence, 5-''year sur'­vival and mortality

An accom'­pa'­nying edi'­torial by Dr. Vir'­ginia Moyer, a' Pro'­fessor of Pedi'­atrics and current Chair of the USPSTF, drives two mes'­sages in her title, What We Don't Know Can Hurt Our Patients: Physician Innu'­meracy and Overuse of Screening Tests.' Dr. Moyer is right, to a' point. Because if doctors who counsel patients on screening don't know what they're speaking of, they may provide mis'­in'­for'­mation and cause harm. But she over'­states the study's impli'­ca'­tions by empha'­sizing the 'overuse of screening tests.'

The report shows, plainly and painfully, that too many doctors are con'­fused and even ignorant of some sta'­tis'­tical con'­cepts. Nothing more, nothing less.' The new findings have no bearing on whether or not cancer screening is cost-''effective or life-''saving.

What the study does suggest is that med school math require'­ments should be upped and rig'­orous, counter to the trend. And that we should do a' better job edu'­cating stu'­dents and reminding doctors about rel'­evant con'­cepts including lead-''time bias, over'­diag'­nosis and ' as high'­lighted in two valuable blogs just yes'­terday, NPR Shots and' Reporting on Health Antidote ' the Number Needed to Treat, or' NNT.

The Annals' paper has yielded at least two unfor'­tunate out'­comes. One, which there's no way to get around, is the clear admission of doctors' con'­fusion. In the long term, this may be a' good thing, like admitting a' medical error and then having QA improve as a' con'­se'­quence. But mean'­while some doctors at their office desks and lecterns don't realize what they don't know, and there's no clear remedy in' sight.

Dr. Moyer, in her edi'­torial, writes that medical journal editors should care'­fully monitor reports to ensure that results aren't likely mis'­in'­ter'­preted. She says, in just one half-''sentence, that medical edu'­cators should improve teaching on this topic. And then she directs the task of stats-''ed to media and jour'­nalists, who, she advises, might follow the lead of the 'watchdog' Health'­News'­Review. I' don't see that as a' solution, although I' agree that jour'­nalists should know as much as pos'­sible about sta'­tistics and limits of data about which they report.

The main problem elu'­ci'­dated in this article is a' failure in medical edu'­cation. The cat's out of the bag now. The WSJ Heath Blog covered the story. Most doctors are baffled, says Fox News. On its home page, the Dart'­mouth Institute for Health Policy & Clinical Practice' links to a' Reuters article that's landed on the NIH/'NLM-''sponsored Med'­linePlus (accessed 3/15/12).' This embar'­rassment ' further com'­pro'­mises indi'­viduals' con'­fi'­dence in doctors they would and some'­times need rely' on.

We lie, we cheat, we steal, we are confused'' What else can doctors do' wrong?

The second, and I' think unnec'­essary, prob'­lematic outcome of this report is that it's been used to argue against cancer screening. In the edi'­torial Dr. Moyer indulges an ill-''supported statement:

'several analyses have demon'­strated that the vast majority of women with screen-''detected breast cancer have not had their lives saved by screening, but rather have been diag'­nosed early with no change in outcome or have been overdiagnosed.

The problem of over'­diag'­nosis, which comes up a' lot in the paper, is over-''emphasized, at least as it relates to breast cancer, colon cancer and some other tumors. I ' have never seen a' case of van'­ishing invasive breast cancer. In younger women, low-''grade invasive tumors are rel'­a'­tively rare. So over'­diag'­nosis isn't applicable in BC, at least for women who are not elderly.

In the second para'­graph Dr. Moyer out'­lines, in an unusual mode for the Annals, a' cabal-''like screening lobby:

'pow'­erful non'­medical forces may also lead to enthu'­siasm for screening, including financial interests from com'­panies that make tests or testing equipment or sell products to treat the con'­di'­tions diag'­nosed and more subtle financial pres'­sures from the clin'­i'­cians whose daily work is to diagnose or treat a' con'­dition. If fewer people are diag'­nosed with a' disease, advocacy groups stand to lose con'­tri'­bu'­tions and aca'­d'­emics who study the disease may lose funding. Politi'­cians may wish to appear responsive to pow'­erful special interests'

While she may be right, that there are some influ'­ential and self-''serving interests and cor'­po'­ra'­tions who push aggres'­sively, and maybe too aggres'­sively for cancer screening, it may also be that some forms of cancer screening are indeed life-''saving tools that should be valued by our society. I' think, also, that she goes too far in insin'­u'­ating that major advocacy groups push for screening because they stand to lose funding.

I've met many cancer agency workers, some founders, some full-''time, paid and vol'­unteer helpers ' with varied pri'­or'­ities and goals ' and I' hon'­estly believe that each and every one of those indi'­viduals hopes that the problem of cancer killing so many non-''elderly indi'­viduals in our society will go away. It's beyond reason to suggest there's a' hidden agenda at any of the major cancer agencies to 'keep cancer going.' There are plenty of other worthy causes to which they might give their time and other resources, like edu'­cation, to name' one.

Which leads me back to the original paper, on doctors' limited knowledge '

As I' read the original paper the first time, I' con'­sidered what would happen if you tested 412 prac'­ticing primary care physi'­cians about hepatitis C' screening, strains, and whether or not there's a' benefit to early detection and treatment of that common and some'­times patho'­logic virus, or about the use of aspirin in adults with high blood pressure and other risk factors for heart disease, or about the risks and ben'­efits of drugs that lower cholesterol.

It seems highly unlikely that physi'­cians' uncer'­tainty is limited to con'­ceptual aspects of cancer screening stats.' Knowing that, you'd have to wonder why the authors did this research, and why the edi'­torial pushes so hard the message of over-''screening.

More Blog Posts by Elaine Schattner

Elaine Schattner, M.D., is a trained oncol­ogist, hema­tol­ogist, edu­cator and jour­nalist who writes about med­icine. Her views on health care are informed by her expe­ri­ences as a patient with sco­l­iosis since childhood and other con­di­tions including breast cancer. She is a Clinical Asso­ciate Pro­fessor of Med­icine at Weill Cornell Medical College, where she teaches part-time. She holds an active New York State medical license and is board-certified in the Internal Med­icine sub­spe­cialties of Hema­tology (blood dis­eases) and Oncology (cancer medicine). She writes regularly on her blog, Medical Lessons. You can follower her on Twitter @ElaineSchattner.

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Disease Screening   Communicate with your Doctors   Lifestyle and Prevention   Cancer   Elaine Schattner  

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