I 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.
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.
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