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Book Review: Don’t Be Such A Scientist: Talking Substance In An Age Of Style

Preamble

I’ll never forget the day when I argued for protecting parents against misleading and false information about the treatment of autism. I was working at a large consumer health organization whose mission was to “empower patients with accurate information” so that they could take control of their health. My opposition was himself a physician who requested that our organization publish an article that advised parents of children with autism to seek out DAN! practitioners and chelation therapy.

I prepared my remarks with the utmost care and delivered them to a committee of our lay executives. I cited examples of children who had died during chelation treatments, explained exactly why there was no evidence that chelation therapy could improve the symptoms of autism and in fact was based on the false premise that “heavy metals” in vaccines were implicated in the etiology of the disease. I concluded that it would be irresponsible for the company to publish such misleading advice/information for parents, and would in fact be counter to our entire mission.

My physician opponent suggested that it was our company’s duty to inform parents of all their options, that we should not be judgmental about treatments, and that I was part of a paternalistic medical establishment that tried to silence creative thinking.

The committee ended up siding with my opponent. I was flabbergasted and asked one of the committee members what on earth they were thinking. She simply shrugged and said that my opponent was more likable than I was.

This experience marked the beginning of my journey towards fighting fire with fire – understanding that being right is not the same as being influential, and that “winning” an argument (where lives are on the line) requires a different skill set than I learned in my scientific training.

Book Review

And so it was with great interest that I picked up Randy Olson’s book, Don’t Be Such A Scientist: Talking Substance In An Age Of Style. I was pleased to see that other scientists had experienced the same revelation – that we need to be more communication-savvy to become more societally-influential.

Olson’s book outline is simple: four “don’ts” and one “do.” Don’t be so cerebral, literal-minded, poor at telling stories, or unlikeable. Do be the voice of science. He begins his book with a captivating story: a marine biologist goes to Hollywood and is shredded by an acting teacher for being incapable of raw emotion. Most scientists will get a good chuckle out of this narrative and will relate to Olson’s culture shock.

As the book winds along, the reader is introduced to a series of the author’s former girlfriends. He reminisces:

She would listen to me talk and talk and talk to the old folks and finally, by the end of the day, she would have had enough. So her favorite thing to do in the evening was, when I was done talking, to look deeply, romantically, lovingly into my eyes and say in a soft and seductive Germanic voice… “You bore me.”… p.82

Another girlfriend developed an affectionate nickname for me, “Chief Longwind,” which she would abbreviate when I’d get going on something and just say, “That’s enough for tonight, Chief.” p.83

Unfortunately, as these ladies noted, Olson’s strong suit is not compelling dialog – a tragic irony for a book written to inspire more effective science communication. Nonetheless, since scientists are rarely deterred by boredom, I think that there are some conceptual gems worth unearthing.

These are my top 5 take-home messages:

1. Communicate in a human way – be humorous, tell stories, don’t feel as if you have to present all the details. The goal is to get people curious enough to ask more questions.

2. Broad audiences prefer style over substance – learn to be bilingual (to speak with academics versus a general audience).

3. Marketing is critical for influence. The creators of Napoleon Dynamite spent a few hundred thousand dollars on production and $10 million on advertising/marketing. The movie grossed $50 million. Scientists who wish to be influential (or get their message across broadly) must bow the knee to the marketing gods.

4. Some people are naturally good communicators, others are not. Find the good ones and make them  spokespeople. “The strongest voice is that of a single individual.” p. 166

5. Likability trumps everything. People make snap judgments about whether or not they like you, and your message’s impact is dependent upon your likability factor. Likability is related to humor, emotion, and passion. p. 148

And so, Don’t Be Such A Scientist offers some great food for thought – and I suppose if it hadn’t been written by a scientist it might also have been a more engaging read! But who am I to say, I’m still trying to bend my mind around the idea that Americans don’t care about facts.

Counter Point: Healthcare Reform Won’t Impact Your Freedom

Congress is going into recess without completing its work on health insurance reform, and the advocacy groups are eager to use this time to whip up voter sentiment for or against reform.  Unfortunately, the anti-reform pundits are all-too-ready to dip right back into the 1993 playbook that gave us Harry & Louise, playing on the fears of consumers with distortions and outright lies.

Ramona alerted me to one such piece published in the CNN/Money-Fortune segment, a “Special Report,” scarily titled:

5 freedoms you’d lose in health care reform

Nice lede, eh?  Can you guess without reading the article where this author is coming from?

The subsequent bits range from “accurate-but-deliberately distorted” to “complete BS that I made up but is really scary.”

Let’s start with the latter, as it’s more fun:

5. Freedom to choose your doctors

The Senate bill requires that Americans buying through the exchanges […] must get their care through something called “medical home.” Medical home is similar to an HMO. You’re assigned a primary care doctor, and the doctor controls your access to specialists. The primary care physicians will decide which services, like MRIs and other diagnostic scans, are best for you, and will decide when you really need to see a cardiologists or orthopedists.

Under the proposals, the gatekeepers would theoretically guide patients to tests and treatments that have proved most cost-effective. The danger is that doctors will be financially rewarded for denying care, as were HMO physicians more than a decade ago. […]

The bills do not specifically rule out fee-for-service plans as options to be offered through the exchanges.

So, just to recap: You won’t be able to choose your doctors because your primary care doctor (that you chose) might, under certain reimbursement schemes that aren’t actually mandated in the bill, have a hypothetical incentive to limit access to specialists.

Um, what?

Never mind the fact that TODAY, right now, your access to a specialist is limited by some drone at your insurance company who doesn’t have a medical degree and does have a very powerful direct financial incentive to deny authorization for referrals.  Never mind the fact that there is nothing in the bill which states you will be “assigned” to a primary care doctor.  Never mind that fact that the “Medical Home” is not in any way related to an HMO, conceptually or practically. This “gatekeeper” function isn’t in the bill at all!  The medical home concept is designed not to ration care (which is the unspoken subtext of the above passage) but to coordinate and improve the quality of care.  Never mind that, if a referral is granted by the wicked & parsimonious gatekeeper, your choice of a doctor is still not restricted under the bill.

Never mind all those inconvenient little facts that each individually or all together totally invalidate the thrust of the author’s argument.  The problem for the whole concept is that there will be many plans offered for purchase on the exchange. If you don’t like the one you picked because it is too restrictive, you can switch to another plan! If WellPoint requires too much hassle to get to see a specialist, then you can dump them and pick Cigna!  Granted, the ones which are more restrictive are also probably going to be cheaper, but that’s for the consumer to choose!

And yes, before you bother to say it, yes, this might result in adverse selection of sicker patients into the more lenient plans, but they will be risk-adjusted to correct for imbalances in their patient populations.

So that’s the easy point to debunk, and I would think that finishing up with the BIG LIE like that, there would be little need to review the rest of the hit-piece, but I’ll make the effort, my love of truth and good policy being as strong as it is.  Other “freedoms” you would lose, according to the esteemed and honorable author:

1. Freedom to choose what’s in your plan
3. Freedom to choose high-deductible coverage

I put these together, because it’s a bit of a cheat on the author’s part to list them separately.  I mean, it’s the same thing, innit?  This is basically an assault on the concept of the mandate that all Americans be insured: you can’t just buy crappy insurance that doesn’t really cover anything meaningful and say that you’re covered.  I respect those libertarians I have clashed with when they say that they should be free to “go naked” if they so choose, and have no or minimal insurance if that is their choice.  I disagree, but I respect their honesty.  This piece is a little less direct, but it’s basically the same thing — defending the right of people to choose crappy insurance that wouldn’t actually cover their health care needs should they fall ill.

There are two problems with that sort of policy approach.  First, a fig leaf just ain’t clothing.  You can glue one on and walk around town without getting arrested, but everybody who sees you knows you’re naked.  Insurance that has the “We never pay” clause just isn’t actually insurance.   It doesn’t accomplish the actual goal of getting every American access to quality health care.

The other problem, a bit more subtle, is that letting people opt out of health insurance, either explicitly or de facto by buying cheap fig-leaf insurance, defeats the purpose of the individual mandate: risk pooling.   It’s a certainty that some of us are going to get sick.  It’s also certain that those of us who do become sick will not be able to pay our individual costs, as health care is now so expensive that no individual can hope to pay their actual bills.  By requiring all of us to have insurance, you create a situation where those huge costs are spread out among the largest possible number of people.  Allowing opt-outs ensures that everybody who can, will, and these will be the healthier people who don’t see a need for insurance, at least not today.  The result is a concentration of costs among the sick people who generate the most costs, which, as noted, exceed the ability of these individuals to pay.  Of course, as people who were healthy become ill, according to nature’s inexorable dictates, they will transition from the low-cost insurance products they previously favored to the ruinously expensive plans that actually cover for people who are sick.  And the system literally falls apart.  No funding exists for the sick to pay for their (hugely expensive) health care, and the healthy contribute little (until they become sick).

2. Freedom to be rewarded for healthy living, or pay your real costs

This is pretty tightly related to the above point, with a slight distinction.  Again, as pointed out, nobody who is sick can pay their real costs.   So again, there’s the risk-pooling issue.  But there’s another, more pernicious assumption here: that health is a controllable feature of lifestyle.

Bullshit.  I’m healthy, and I like to assume that’s because I’m virtuous and athletic and take care of myself.  Right?  Except that it’s strictly a matter of luck that it was not my kid that got sick and died of neuroblastoma.  Or medulloblastoma.  It was a matter of luck that my wife pointed out a funny-looking freckle that turned out to be a very thin melanoma (and lucky for her that she married someone who could tell the difference).   Cancer is easy to cite, but the list goes on and on of health conditions that have nothing to do with lifestyle: crohn’s disease, MS, bipolar, Type 1 diabetes, glomerulosclerosis, etc, etc, etc.   And none of us know in advance when our — or our family’s — number is up.

So we are all in this together.  We all pay a premium: and bet or a hedge against illness.  Those of us who win the genetic lottery and stay healthy lose the “bet” and wind up paying for a service we didn’t need.   If you let some people hitch a free ride and pay a minimal premium, they are not paying their fair share to cover the cost of those who have already become ill.  When President Obama talks about “Shared Responsibility,” this is what he means.

There’s a lot more chicanery in this article — I’ve neglected Point #4 entirely, as I covered that the other day.  No plan will remain the same in perpetuity.  I’ll stick to the main policy points and leave, for the moment, the sly little insinuations and falsehoods scattered throughout the article like so many candy sprinkles on an ice cream cone.

Strangely enough, I’ve finally found a point of serious, substantive agreement with (former) Alaska governor Palin.  She and I are united in wishing that the gosh-darned liberal media would just stop making stuff up.

*This blog post was originally published at Movin' Meat*

Media Malpractice: H1N1 Fear Mongering In NYC

Friends visiting New York City this summer keep asking if it’s safe. As in, will they be catching and suffering from novel H1N1 (swine) flu.

I like to think my friends are pretty sharp, discerning folks (after all, they’re choosing my company) so I have to attribute these inappropriate questions to a wider problem.

For reference, here’s the latest and thought probably not last NYC DOH guideline on H1N1, which notes about 900 hospitalization and 45 deaths in H1N1+ patients over three months. About three quarters of these patients had at least one risk factor such as existing lung disease.

This deaths and hospitalizations are concerning, naturally, but some perspective is in order: as many as half a million New Yorkers have been infected with H1N1, and this spring in US cities, we actually saw a smaller fraction of deaths due to infectious respiratory illness, compared with 2008. Also, for reference, based on data from a few years ago, I’m guessing that any given three month period, there are between 10,000 to 15,000 deaths in New York City.

So why were ED’s swamped in May? Why are my friends still afraid to come to NYC? Dr. David Newman has some thoughts in EPMonthly:

…with constant messages of swine flu lethality on the nightly news, it is little surprise that ED’s in New York City, departments in a chronic state of over-crowding and crisis, were soon bursting at the seams with record volumes. In some institutions daily ED volumes doubled, as EP’s worked through third-world conditions of extreme crowding, questionable hygiene, extended wait times, and swarms of infectious, coughing congregates all within arm’s reach of each other.

The impact is clear: lives were lost. High quality studies have shown repeatedly that when ED’s experience crowding patients in need of rapid, high intensity care are identified later, treated more slowly, and devoted fewer resources. Mortality goes up during crowding in virtually every condition that has been studied, including MI, sepsis, and others. The irony is stark: Once a critical mass is reached, the more that come to be saved, the fewer we can save.

…The overall management of information during the swine flu of 2009, despite some progress in our access to information, was misguided and dangerous. Frantic media outlets drove a nation to fabricated fears, while state-level institutions not only failed to contain or counteract these messages, but also used expensive, fruitless, prescription-only pills, available to most only in their local ED’s, as a means of false comfort. Instead of using honest information to provide safety, comfort and education, the approach created panic, cost money and resources, and took lives.

All of this was preventable and is reversible for the future. There is no reason why the media cannot be recruited into the information dissemination process…

Unfortunately, there is a good reason why: Responsibly framing public health risks is no longer a role that suits traditional media. They’ve decided it’s just not in their interest.

I remarked on this years ago with West Nile virus, which never will never kill as many as, say, food poisoning or swimming pool accidents.

There are many factors driving the public appetite for health risk information — and that’s understandable. I think it’s even ok for news organizations to shuffle around reporting to some extent, to satiate those desires.

But what happened in NYC this spring was media malpractice — night after night, opportunities to put the risks of swine flu in perspective were passed up for breathless reporting. I recall one occasion in which a phalanx of reporters were camped outside a hospital I worked at, providing next to no detail about an infant who died it respiratory distress. It turns out this child did not have H1N1, but communicating that was not a priority — by the next day the lead story was ED’s are overcrowded and schools are closing.

EPMonthly ran a nice sidebar from Dr. Jim Augustine, enumerating the ways in which ED docs can engage the media to get the right message out.

But I’m more encouraged by approaches to bypass traditional media and reach patients directly. Yesterday I heard some encouraging news from the CDC: their emergency twitter feed has over 500,000 followers. Millions saw their videos. This is amazing reach, for public health communication.

It wasn’t enough to help ED’s this spring. But individual hospitals and the CDC is ramping up their use of social media, even as traditional news sources decline in influence. It’s really the first good viral news I’ve heard in a while.

*This blog post was originally published at Blogborygmi*

The Oprah-fication Of Medicine

OprahUnfortunately, a frequent topic on SBM has been the anti-vaccine movement, personified these days by celebrity spokesmodel for Generation Rescue Jenny McCarthy and her  boyfriend comedian and actor Jim Carrey. Unfortunately, it is a topic that is unlikely to go away. We’ve all speculated why the anti-scientific emotion-based notion that vaccines somehow must cause autism persists in spite of mountains of evidence to the contrary, but I think the question goes much deeper than that because it’s not just about vaccines. The anti-vaccine movement is but one of the most visible components of a much deeper problem in our public discourse, a problem that values feelings and personal experience over evidence, compelling stories and anecdotes over science.

I’m referring to the Oprah-fication of medicine in America.

Why Oprah? you may ask. I’m happy to tell you. Oprah Winfrey has been the host of the highest rated syndicated talk show in television history, her self-named The Oprah Winfrey Show. The show has been running for nearly 23 years, with over 3,000 episodes. Winfrey is so famous that she is one of those rare celebrities who is known instantly by just her first name. Say “Oprah,” and virtually everyone will know to whom you’re referring, and her show is often colloquially known as simply Oprah. Given this unprecedented level of success, which has made Oprah a billionaire and a ubiquitous presence on TV, her own magazine, her own satellite radio station, and, soon, her own cable channel, Oprah has developed a media empire that few single individuals can match or beat. Indeed Rupert Murdoch is the only person that I can think of who likely has a wider reach than Oprah. Personally, I have no problem with Oprah’s level of success. Clearly, she is a very talented and savvy TV host and businesswoman.

Unfortunately, in marked contrast, Oprah has about as close to no critical thinking skills when it comes to science and medicine as I’ve ever seen, and she uses the vast power and influence her TV show and media empire give her in order to subject the world to her special brand of mystical New Age thinking and belief in various forms of what can only be characterized as dubious medical therapies at best and quackery at worst. Arguably there is no single person in the world with more influence pushing woo than Oprah. Indeed, she puts Prince Charles to shame, and Kevin Trudeau is a mere ant compared to the juggernaught that is Oprah Winfrey’s media empire. No one even comes close. No one, and I mean no one, brings pseudoscience, quackery, and antivaccine madness to more people than Oprah Winfrey does every week. (She doesn’t discuss such topics every day, but it seems that at least once a week she does.) Naturally, Oprah doesn’t see it that way and likely no one could ever convince her of the malign effect she has on the national zeitgeist with respect to science and medicine, but that’s exactly what she does. Consequently, whether fair or unfair, she represents the perfect face to put on the problem that we supporters of science-based medicine face when trying to get the message out to the average reader about unscientific medical practices, and that’s why I am referring to the pervasiveness of pseudoscience infiltrating medicine as the “Oprah-fication” of medicine.

Read more »

*This blog post was originally published at Science-Based Medicine*

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