August 22nd, 2011
CNN, ABC, and NBC Dumb Down the News About CV Screening
Larry Husten, PHD
Last Thursday the Lancet published an extraordinarily interesting and complex study looking at the relative value of CRP tests and CAC (coronary artery calcium) scans (see my news report here). Coincidentally, CNN, NBC, and ABC this week ran reports on the same general topic. Exit complexity. Enter stupidity.
Health journalism watchdog Gary Schwitzer and his Health News Review has a definitive takedown on these reports (here, here, and here). I just want to call attention to some of the major flaws of these pieces, and then take a peek behind the curtain to show how these news organizations actually take great effort to dumb down their stories.
The CNN story, “Will you have a heart attack? These tests might tell,” pumps calcium imaging. It relies heavily on cardiologist Arthur Agatston, the South Beach Diet guru and an early advocate of calcium scans. Two of his quotes are perfect examples of what good health journalism should always avoid. Here’s the first:
“Unless you do the imaging, you are really playing Russian roulette with your life,” he said.
And here’s the quote that concludes the story:
“One of the best-kept secrets in the country in medicine is the doctors who are practicing aggressive prevention are really seeing heart attacks and strokes disappear from their practices. It’s doable.
Here’s what the reviewer on Health News Review had to say about this assertion:
The claim that a few screening tests can make heart attacks and strokes disappear flies in the face of even the most optimistic interpretations of recent studies that indicate some incremental advantage to adding coronary calcium scoring to risk fact calculations for certain patients.
The same pattern holds over on ABC. Dr. Richard Besser narrated a short piece that actually focused on an important issue, which is that low cholesterol is no guarantee of safety. But then he offered this advice:
“Before you go on a cholesterol medication, I want you to ask your doctor about this: A coronary artery calcium test.”
Now this is a completely unwarranted recommendation. Responding to criticism from Schwitzer, Besser said on Twitter that his goal was to empower patients, and then he made this claim:
I practice public health from my perch at ABC News. Would I stop at “Experts recommend flu vaccine?” No!
Make no mistake: although there is some dissent, there is a very broad consensus within the medical community about the flu vaccine. Although calcium scans have some very passionate advocates, there is absolutely no consensus within the medical community about their precise role, and Besser does a huge disservice to ABC viewers by pretending otherwise.
Over on NBC’s Nightly News, Dr. Nancy Snyderman uncritically pumped the value of CRP for women over 40:
“It’s not a new test, it’s not an experimental test, but nonetheless it’s a test not a lot of people know about. And that’s a problem because this simple blood test could save your life.”
Too often, according to Snyderman, women who think they’re at low risk end up having heart attacks. Says Snyderman:
“… that’s because most doctors do not check for C-reactive protein for fear of overtreating them.”
Snyderman concludes:
“If you’re over the age of 40, this is the time to have a conversation with your doctor about this very simple blood test that’s covered by most insurance.”
Once again, Snyderman’s report includes no caveats, and it fails to inform viewers that the role of CRP in preventive cardiology is highly controversial and the subject of intense debate. CRP is certainly not a “very simple blood test,” and until a larger consensus is achieved, TV docs like Snyderman shouldn’t blithely endorse its use.
Case History of a Quotation
In the CNN report discussed above the Agatston quotations struck me as particularly egregious, but I was also bothered by another quotation, which included the incredible assertion that half the population might benefit from a calcium scan. Here’s the entire relevant portion of the CNN article:
High-risk patients already receive such aggressive treatment as cholesterol-lowering statin medication, but many doctors don’t think low-risk patients need to incur the expense or small dose of radiation that comes with a coronary calcium scan.
“There is a large group in the middle called intermediate risk, which may be as much as 50% of the population,” said Dr. Erin Michos, a cardiologist at the Ciccarone Center for the Prevention of Heart Disease at Johns Hopkins University
A good candidate for a coronary calcium scan, she says, would be a 50-year-old man with slightly elevated cholesterol and a father who had a heart attack.
“Do you put this 50-year-old who has this family history on a statin medication with potential expense (and) side effects for the next four decades of his life, or do you further refine how far at risk he is?” she asked.
A calcium score would answer that question, she says.
I asked Erin Michos about the quote. Here is her response:
My quotes in the CNN article were taken out of a much longer 30-minute interview about prevention (an interview where I tried to be balanced and evidence-based), and I actually did not see the article or get to approve the proofs before it published.
I actually never said that 50% of adults need a CAC scan. I did say, depending on the definition of intermediate risk (see below regarding definitions), that “intermediate risk” can be 50% of a middle-aged to older adult population (i.e., men 45-74, women 51-74).
Actually, Michos’s response was much longer than this, and she sent me a second email with additional clarifications and explanations. Clearly, this is not a person likely to make a broad and completely unqualified statement along the lines that fully half the population might benefit from calcium scans. But clearly the folks at CNN thought Michos’s message was too complex for their audience, and so they extracted the nugget they wanted and ignored everything else.
From conversations I’ve had in the past with many physicians and researchers who have been interviewed and quoted in the press, this is by no means an unusual or atypical occurrence. Unfortunately, it appears to be the norm for health journalism.
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Just a brief followup:
In response to the criticism from Gary Schwitzer and myself, ABC’s Richard Besser asked his followers on Twitter:
What do you think? Did I get it wrong?
So Besser gives the appearance of being open-minded, and who could find fault with that? But here’s the problem: health journalism shouldn’t be a popularity contest. I guess if you live in the world of television, where you live and die by the ratings, then this might seem like a good way to assess what you do. But it’s not. It’s dangerous. It doesn’t lead to the slippery slope. It is the slippery slope.
Instead of asking his viewers, Besser should ask himself if he got it wrong. He should engage the issues raised by Schwitzer and myself and he should apply the intellectual training he presumably received in medical school, along with the basic, common sense principles of journalism.
Media inaccuracy due to deletions, oversimplificaction, misinterpretation, distortion so the thrust of the article carries spin to support individual/sponsor/corporate agendas, modification to appeal to their specific audience and to maintain sales and position in online media engines, or simply because the writer is unable to grasp the nature of the subject matter, is common. Press releases carrying the agenda of the authors and sponsors and weight given to reputations of journals, generally influenced by pharmaceutical houses (about 35% of studies are funded by them) are prominent sources. http://www.scientificamerican.com/blog/post.cfm?id=health-reporting-and-its-sources-2011-05-31&WT.mc_id=SA_CAT_HLTH_20110531.
Media reporting of health issues was rated as poor in two recommended pieces in PLoS Medicine in May 2008 [Schwitzer G. How do US journalists cover treatments, tests, products, and procedures? An evaluation of 500 stories. PLoS Med. 2008;5(5:e95 DOI:10.1371/journal.pmed.0050095
The PLoS Medicine Editors. False hopes, unwarranted fears: The trouble with medical news stories. PLoS Med. 2008;5(5):e118 DOI: 10.1371/journal.pmed.0050118]
Let’s not single out health… the same applies to most of what is written nowadays, basically a balance or blend of competing self-interests and agendas. Self-preservation carries the highest priority.
As far as CRP and CAC are concerned, both are extremely useful, and neither is “worthless,” as is sometimes declared when speaking about the other. The jump from mere performance of a single test to saving a particular life as a result is much. I believe when physicians use such language to patients, it is more a shortcut to avoid going into the complexities of the evidence, precluded by time, and to encourage adherence–actually having a test done. Perhaps a bit of “translational license” for practical reasons rather than to mislead a patient. When amplified by an appearance in public media, these statements seem somewhat exaggerated. But in commercial magazines, common news sites, and newspapers, they are expected by the audience…
Concerning the individual remarks by the physician-researchers in all related commentary here and elsewhere about “competing” biomarkers, familiarity with their various publications, seminars, blogs, and other professional activities, including personal contact, really convinces me that these professionals either did not make such blatant statements, or that upon closer questioning, qualifications to their comments would clarify their intent.
Nonetheless, improvement in media reporting of medical controversy, as well as new reports in noncontroversial areas, would be welcome and timely.
Richard Kones
How can a journalist be criticized for saying “ask your physician about….” ? The fact is that traditional risk factors have been shown over and over to mis-characterize the majority of subjects who have heart attacks as not qualifying for statin therapy until after they have their first event.
Coronary calcium has been shown to be 10 times more predictive of MI risk than all risk factors combined.
Steve Nissen has demonstrated a level of subjective bias regarding coronary calcium imaging to the point that his comments lack objective credibility. His contrived outrage about this most valuable test has become the comic relief in medical discussions.
I am glad that Dr. Richard Besser had the courage to speak the truth. How is it that you criticize Dr. Besser for suggesting a conversation with your physician about coronary calcium but give Dr. Nissen a free pass to repeatedly fire personal insults at the researchers who are investigating coronary calcium and allow him to mis-characterize the utility of the test without comment?
As a clinician, you can have your opinions however when the facts are available, please consult them before you criticize.
Put away your lantern Diogenes, we have found Dr Besser, an honest man.
Competing interests pertaining specifically to this post, comment, or both:
I work at and have an ownership interest in a facility that does EBT calcium imaging and carotid ultrasound to identify heart attack and stroke risk. In a population of intermediate risk mostly medicare aged patients, our annual experience for heart attacks and ischemic strokes combined is roghly 0.06% annually over the last 6 years, in other works less than 10% of the expected incidence. Dr. Agatston is correct.
Great summary, Larry.
Revisiting these comments… at first I smiled because of the truth in Larry’s presentation. Then I pondered, a bit unhappy. I then tried to reconcile the dilemmas. The final reaction, sadness, made me realize I was going through stages of grief.
I sometimes wonder whether our present technologically-advanced practice, with all the paper-pushing has so much more to offer than the dark (or golden) days of medicine in the 60s. Although I would not want to be back there, there is something nostalgically simple that we might learn from. A prominent physician’s daughter came in the other day and told me about her Mom’s UTI. Although fairly straightforward from the summary, she was referred, tested, reseen, studied, and followed-up remarkably well. She complained of the need to accompany her cognitively-impaired mother on so many trips. Outcome-simple UTI responsive to several classical antibiotics. Cost, added up: shocking. I mulled the outcome when compared to an old-time GP, who would have given the same classic ABX after a single routine office visit. That GP had the courage to believe in his ability. While there is plenty to say against this, beginning with “what if…” there is more to say in its favor. Certainly, changes are needed.
No, putting a serious academic question, with much objective data now available, out to an untrained public without the capacity to understand the issue, to vote for or against, is not the way to go. A few years ago, I read of an herbalist who joined the call for a “different way” to judge alternative therapies, because the physicochemical, statistical methods of the scientific method used in medicine were not producing satisfactory results for them–ie, their products did not “work.” Among the methods he proposed: give “credit” to the herb according to the number of years of “traditional use”, and/or take public votes of which users were satisfied with the result, thereby incorporating the effects of placebo and advertising.
The proper way for medicine to go is outlined by Dr Harlan Krumholz in a gem that appeared in JAMA August 17, 2011 http://jama.ama-assn.org/content/306/7/754.full. This is priority reading for all physicians. There is also a 3 paper series on Health Policy and Systems Research in PLoS Medicine this month in a Policy Forum of interest.
Richard Kones