Much has been made of Mark Cuban’s medical knowledge since he tweeted, “If you can afford to have your blood tested for everything available, do it quarterly so you have a baseline of your own personal health”. Charles Ornstein shared the tweet and many physicians and others, myself included, weighed in on the costs and potential for harm from unnecessary testing.
I’ll admit that, when I tweeted to him, I expected Cuban to agree. But he didn’t. In fact, he grew increasingly resistant. I stopped responding when he announced that the opposition to his idea his had convinced him he needed to take his proselytizing to his TV show.
Instead of poking the sore, I began to wonder about the origins of Cuban’s conviction. I remembered that he is not alone in wanting tests that clinicians who worry about value, cost, and harm think he shouldn’t have.
But where do these attitudes come from? Is it possible that clinicians are contributing in any way to this situation? Quite the contrary: most Americans want tests, even when you tell them that nothing can be done with the information. Furthermore, Americans are more convinced of the benefits of tests like mammograms than people in other countries, and then go out and get more of them.
I think that we are. My team has studied why patients get so many electively placed coronary stents, when cardiologists readily admit that randomized trials have demonstrated that there are few situations in which such stents improve survival or reduce the risk of heart attacks.
Studies of the beliefs of patients who have just received an electively placed stent give a big clue: 80% thought stenting would reduce their risk of death, even though their cardiologists knew that this was not the case.
One might think that such misunderstandings occur because medicine is complex and we have to give patients lots of information in short period of time. However, I think that lets us clinicians off the hook too easily. There is ample evidence that clinicians and clinical organizations actively lead the public to overestimate benefits and underestimate harms.
A study of news releases from US News and World Report top 50 hospitals, for instance, show that those hospitals often overstate the potential impact of research studies and fail to mention important caveats. For instance, only 10% of news releases about animal studies note that the findings might not translate to humans, while only 1 in 6 news releases about uncontrolled studies of clinical interventions mention that there is no control group.
(One could even ask why a top research institution would ever issue a news release about an uncontrolled study, but that’s what 5% of the news releases were.)
In a recent study of 262 hospitals that offer Transcatheter Aortic Valve Replacement (TAVR, a procedure recently approved by the FDA), researchers found that the hospitals’ web pages devoted to TAVR almost always described the benefits, but mentioned any risk at all less than 30% of the time. There are no length limits on web pages, nor does it cost more to put more information on them, so it is hard to think of why this important issue usually goes unaddressed.
It’s not just hospitals that ignore information that suggests common practices aren’t beneficial. In a recent review of specialty society responses to new data that challenged standards of practice, societies in their communications to members recommended continued use in spite of the new evidence most of the time, while editorial writers in scientific journals did so less than 30% of the time.
So, if we, as clinicians and clinical organizations, tend to overstate the benefits of our work, understate the associated risks, and resist information that suggests we shouldn’t be doing it, those are the messages our patients are likely to receive.
Mark Cuban has a doctor he’s been happily working with for years, collecting unnecessary data without any pushback. When he mentions this on Twitter, a few physicians on Twitter tell him there’s potential for harm, but the vast majority of Twitter docs are silent. Then he reads stories written off hospital press releases and sees clinicians’ web pages, and comes to the conclusion that we can do more than we can.
Unfortunately, in this case, Mark Cuban isn’t being a maverick. Instead, he’s accepting the conventional wisdom as presented for years by us, the clinicians and hospitals around him.
We have to shoulder at least some of the blame for his opinion. And we can start to fix it today.
Adams Dudley, MD is Professor of Medicine and Director of UCSF’s Center of Health Care Value.