OP-ED

Overoutrage and the Asymmetric Skepticism of Healthcare Journalists

flying cadeuciiI like healthcare journalists. Some of my best friends are healthcare journalists. I’d rather read Larry Husten on clinical trials than the constipated editorials in peer review journals. Healthcare journalists are an important force against overdiagnosis, overtreatment, overprescription, overdoctoring and overmedicalization. They’re articulate and skeptical. But they seem to have a blind spot – overoutrage.

Overoutrage is excessive moral outrage. Outrage is excessive anger. Anger is excessive emotion. Emotion is excessive anti-reason. Overoutrage is the mother of all overdoing.

Overoutrage is the healthcare journalist’s kryptonite. These skeptical Rotweillers become credulous poodles when they see overoutrage. Overoutrage axiomatically assumes a moral high ground – for the transgression must have been severe for the outrage to occur. Overoutrage is circular reasoning without an exit. Overoutrage is more powerful than any randomized controlled trial. Much of healthcare policy, indeed civic life, is shaped by it.

A recent event highlights this phenomenon very well. NEJM’s national correspondent, Lisa Rosenbaum, wrote about a surgeon’s determined, and widely publicized, advocacy to ban morcellation, a procedure to treat uterine fibroids. Dr. Hooman Noorchashm’s wife, Amy Reed, underwent morcellation to treat uterine fibroids. Unbeknownst, she had uterine cancer, and the morcellation almost certainly worsened the prognosis by spreading the cancer beyond the uterus. Banning morcellation would be a no-brainer except that morcellation has fewer complications than open surgery for fibroids, and that the chances of undiscovered uterine cancer in a woman with fibroids are exceedingly rare.

In lucid and empathetic prose, Rosenbaum asked why we make policy without a discussion of trade-offs. While banning morcellation certainly saves women from the dreaded complication that Amy Reed regrettably faced, what about women who do not develop complications from open procedure, such as pulmonary embolism, because of using the less invasive technique? Who cheers for events that don’t happen? Safety for some patients comes with unsafety for other patients.

In the essay Rosenbaum asked why science can’t speak to emotion. When you can’t, or don’t wish to, argue about the message of an essay, the best strategy is to discredit the author. The fastidious moral police, that no longer knows what it is policing, that never misses a trick but struggles to miss the point, searched hard for a “gotcha.”

And they found their “gotcha.” Rosenbaum works in the hospital where Reed was treated. Rosenbaum was accused of searching Reed’s medical records and violating HIPAA (she has been cleared of that by an investigation) because she mentioned the stage of uterine cancer in the essay, begging the question how she knew the stage of the cancer.

As a “gotcha” this is both dull and petty, although I must confess to admiring the depths of shallowness overoutrage can sink to. Now, in the culture in which I grew up, people would think it was rather odd that there would be privacy concerns about a case so widely publicized. I have, however, learnt that American exceptionalism comes in various forms. HIPAA is one of them. Overoutrage is another.

How did our skeptical healthcare journalists respond to this accusation? Presumably they decimated the sloppy, self-serving, logic of the accusation, which is nothing more than a jejune and desperate personal attack on the author. Presumably they fought the censorship of debate which overoutrage achieves more reliably than the North Korean regime. Presumably they saw that HIPAA was being used as an instrument to bully the author, rather than protect the patient.

https://twitter.com/ivanoransky/status/710986628295217152

https://twitter.com/charlesornstein/status/711001418463744001

Come on lads! You can do better than this. How about googling “morcellation” or “Hooman Noorchashm Amy Reed?” You might find this. And if you read on, you will run into this line:

“Later imaging tests showed that the cancerous tissue had been spread throughout her abdominal cavity during the surgery, giving her stage 4 cancer, her husband said.”

You don’t need to sneak into the EHR. GIYF.

When the privacy break did not materialize as a scandal, people looked for other, more creative ways, to be indignant. They accused the author of sloppy journalism, of getting her information from the web (ironic given that she was also accused of getting information not from the web), of not hyperlinking her sources, of not saying the stage of the cancer pre-morcellation was a guess.

https://twitter.com/charlesornstein/status/710995470198280192

Really Charles? Is it really the “not framing as a guess” that is bothering you? Or something else?

The whole point of the piece is that neither Reed nor her physicians knew she had uterine cancer before the morcellation. How can Rosenbaum have access to information that only God knew at that time? This would not just be a violation of HIPAA, but a breach of metaphysics of a scale last recorded in the Old Testament. I’m cringing at this accusation. So will you if you pause to think about it.

Have journalists not learnt from the Tim Hunt affair that a storm in a tea cup, instigated by a willful misrepresentation of the context of a statement, can cause a typhoon of pseudo-indignation?

We need healthcare journalists. They balance the ecosystem which is tilted, still too heavily in my opinion, towards therapeutic optimism. But we trust that our truth-seeking, Pulitzer Prize winning journalists – my heroes – know the significance of the truth they’re uncovering. If they lose perspective, if their trade becomes a religion like the rest of journalism, if they descend into convenient good vs. evil narratives such as patients vs. greedy doctors and greedier device manufacturers, what hope is there for common sense?

Noorchashm has accused the NEJM of fascist propaganda. Fascism, as George Orwell noted, has lost all meaning. Apparently, both Trump and Obama are fascists. My wife recently accused me of being a fascist because I refused to watch a chick lit movie with her. In return, I called her a liberal.

I have sympathy for Noorchashm. Fate has been unkind to him. He is not acting irrationally but understandably. He is sticking up for his wife. I’d be lying if I didn’t confess at least an ounce of admiration for him. But I admire Rosenbaum, too, for having the courage to write about a topic so controversial. It is possible to admire both Noorchashm and Rosenbaum.

Healthcare is a complex issue. We should certainly talk trade-offs. But in the end we must ask whether a system which rationally calculates trade-offs is better than one which bows reflexively to anecdotes. I’m not so sure the answer is that clear cut. We’re not geared to be rational, and this may be for good reasons.

In the meantime, I hope Rosenbaum gets an apology.

About the author:

Saurabh Jha is a radiologist and contributing editor to THCB. If you wish to abuse him, he can be reached on Twitter @RogueRad

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17 replies »

  1. Thank you. Your response requires a bit of thinking. But answering only to the last paragraph doesn’t. This is exactly what Dr. Noorschasm campaign has focused on, after his success in getting the FDA to issue the following “Based on currently available information, the FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for uterine fibroids.” So, in the end you are both in full agreement 🙂

  2. Perhaps the Frog is a metaphor for missing the point by a mile. And not silently 🙂

    But the deeply distressed Frog has a point. If my piece was about the exact benefit-harm trade-off of morcellators I,too, would be deeply distressed, because I just spent most of the piece ranting about healthcare journalists, rather than critiquing the evidence-base for morcellators.

    Perhaps the title “Overoutrage: The Asymmetric Skepticism of Healthcare Journalists” was too cryptic for the Frog. Or perhaps, to paraphrase Billie C, it all depends on what the meaning of the word “of” is. So let me explain. I found the credulity of HC journalists in the recent brouhaha about the one paragraph from the NEJM editorial bizarre. Like really bizarre. Here’s a summary of the brouhaha. http://retractionwatch.com/2016/03/22/nejm-no-plan-to-clarify-wording-that-suggested-breached-confidentiality/

    Like the Frog, I have a deference for experts. I wish experts were choosing POTUS. But they’re not. It’s the peanut gallery. And the peanut gallery has opinions. Lots of opinions, different opinions, mostly wrong – in my opinion, I hasten to add. My piece is an opinion about the brouhaha about an editorial discussing whether we should discuss trade-offs in policy-making.

    Note, Froggie – asking if trade-offs should be discussed isn’t saying “morcellators are the best thing since sliced bread.”

    So what about discussing trade-offs in policy-making? Should we be doing it? As the Frog read in the piece:

    “But in the end we must ask whether a system which rationally calculates trade-offs is better than one which bows reflexively to anecdotes. I’m not so sure the answer is that clear cut. We’re not geared to be rational, and this may be for good reasons.”

    I’m on the fence with this one. Rational sounds good in theory, but if we have not been rational yet, it must be for good reasons.

    Brouhahas have opportunity costs. The intellectual energy this brouhaha has consumed would have been better spent discussing how morcellators, and other devices, enter the market without an RCT. No drug can. Now that’s worthy of healthcare journalism.

    SJ

  3. There is a lot of clinical information on this case already reported publicly on this patient. I wonder if Dr. Jha’s critics have any issue with this article, for example? Did this author breach privacy? http://maisonneuve.org/article/2015/11/10/worth-risk/

    I see little reason to suspect HIPAA violation from Dr. Rosenbaum when this high level of detail has already been reported.

    Edward J. Schloss MD
    @EJSMD

  4. Anish,

    I recognize that your appearance on this site is because you know Dr. Jha from your circle of friends/family and from the cardiology circles in Philadelphia – did he ask you if you knew me from before? I know that since we briefly worked together you feel justified in critiquing me – but I assure you your presumption is misplaced.

    Do not make the error of asssuming that you know anything about the public health problem I have highlighted and the serious ethical problem with with Dr. Jha’s ugly writing, in defense of a corrupted establishment and deadly practice that has compromised real lives.

    This is clear cut. Dr. Jha is defending his friend and trying to make a name for himself as an amateur journalist by weighing in on a topic he knows virtually nothing about. But in doing so he is demonstrating an utter lack of understanding for medical ethics, and an incapacity to see the hundred, if not thousands, of women harmed and killed for over 20 years by an incorrect standard of care.

    I suppose your message here makes you a good friend to Dr. Jha. But presume no more than that – and do refrain from instructing me on how to conduct myself in a very big fight that has been a long one and which you have no idea of or expertise in. Rest assured that dogs are barking now because the fight has been won – too little, too late for the guardians of the walls and for these amateur opportunists.

    Stay well,
    HN.

  5. Dr. Noorchashm has now spent years becoming an expert in one disease. How can you even compare? But since you asked, I have never heard Hooman, whom I know well because he joined our large online community for patients with leiomyosarcoma and their caregivers, provide expert opinion outside of his realm of expertise. He would have had a hard time with me if he did, just like Dr. Jha now.

    I would like Dr. Jha to respond and not use proxies. I think his behavior in this instance is deeply disturbing and running away will not silence me. Just ask Matthew 🙂

  6. Kosherfrog

    Sorry but isn’t one of the physicians at the center of the campaign to have this gynecological surgical procedure banned a cardiologist?

    Or is that somehow different because you happen to agree with him?

  7. Hooman,
    I realize you are very upset about this matter, but your approach to those who even deign to have a discussion about this is troubling, and won’t get you to the promised land you seek. Rather than impugn, and belittle Dr. Rosenbaum and Dr. Jha, you would be much more effective saying that you believe the rate of sarcomas is much higher than stated because of _________, and that the major complication rate of an open procedure is much lower than stated because of _____. Can we not have a civil discussion about the tradeoffs here without degenerating into calling people blowhards? I have no axe to grind, I’m not paid by the morcellation companies, and I was never smart enough to get into a Harvard school. Even if you’re saying that regardless of the risk of an open procedure, it wouldn’t be worth the risk of upstaging this particular malignancy – that’s fine. Say it. You are, most unfortunately, uniquely positioned to take such a stand.

    I’ll also say that Drs. Jha and Rosenbaum do not come out for morcellation… Dr. Jha writes:

    “Healthcare is a complex issue. We should certainly talk trade-offs. But in the end we must ask whether a system which rationally calculates trade-offs is better than one which bows reflexively to anecdotes. I’m not so sure the answer is that clear cut. We’re not geared to be rational, and this may be for good reasons.”

    He specifically states that he is not clear which system is better!

    The point here is to have a discussion – your commentary to Dr. Rosenbaum and Dr. Jha, appears to be an attempt to silence those who dare to have a discussion about the matter. Isn’t that fascist? Your attempt to extinguish discussion in the manner you are choosing is counterproductive. You will quickly own the label of “loving husband driven to irrationality by rage and grief.” You have a real point to make that is completely valid – don’t allow it to be drowned out – it only does damage to your cause.

    I realize I run the risk of some fiery personal attacks from you. I hope you relent, and choose not to respond in that vein, not because I’m afraid of your attack, but because I think you’ll find it much more effective.

  8. Dr. Saurabh Jha, it appears that your specialty is in radiation/imaging related to cardiology. How does that make you an expert in assessing the inherent risks of a gynecological surgical procedure?

    Am I mistaken or you have acted as an expert in a medical field clearly removed from your own specialty. Does that represents a great metaphor for the many, many cases of poor clinical care provided to patients suffering from rare conditions treated by doctors who should have said from the beginning “I don’t know”?

  9. PS. Dr. Jha, I recognize that you are a personal friend of Dr. Rosenbaum’s. I suppose the one thing I could say is that chivalry is NOT dead. But clearly personal COIs are very well alive on THCB. I’m sorry, but I thought this Blog is an objective forum for discourse, not a forum for the defense of the establishment (and our pals) or the “peanut gallery”.

  10. Dr. Saurabh Jha,

    https://www.pennmedicine.org/Providers/Profile/saurabh-jha

    I’ve read your article with care:
    https://thehealthcareblog.com/blog/2016/03/20/overoutrage-and-the-asymmetric-skepticism-of-healthcare-journalists/

    When the details of a patient’s medical record are compromised, a federal law has been violated.

    When a writer does not bother to fact check carefully and rants on, bad journalism and defamation are at hand.

    When a powerful medical establishment, its soundbox and individual physicians are willing to accept “trade-offs”, especially AVOIDABLE ones, for the sake of “majority benefit” or “economics”, a “fascist” state is in the making. And because such atrocious ideologies are sugarcoated with high accolades and detached verbiage from on high, today, they are even more dangerous than traditional fascism.

    I assure you, what you have engaged in your writing from the “peanut gallery”, and as a supposed academic physician at a top institution, is not just a philosophical debate. Hundreds, if not thousands, of unsuspecting women have died worldwide for nearly 2 decades from iatrogenically upstaged cancers – prematurely, unnecessarily and avoidably – and using a careless and incorrect surgical practice.

    Dr. Rosenbaum has chosen her orientation and made her reputation by the style of her writing and her methodology – both are terrifically disgusting.

    But I suppose you are too self-absorbed a blowhard to understand what this fight to secure women’s health and medical ethics is all about – kissing up won’t buy you anything, Dr. Jha. Adhering to correct principles, good doctoring and ethical principles will.

    Check yourself, Dr. Jha.

    Hooman Noorchashm MD, PhD.

  11. It’s just extreme pettifoggery masquerading as fine objectivity. Sign of our times.

  12. Outstanding work here Saurabh. Is it possible the reaction stems more from residual anger about Lisa’s COI series?

  13. I really enjoyed reading this. Churlish, outraged journalists resort to HIPAA bullying, taken to task.

    via TweetBot

  14. Shocking that the intersection of academic medicine and journalism should produce pettiness and weaseltry

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