1. Katz, David L. MD, MPH, FACPM, FACP

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We have all long known-at least those of us not living under a rock left behind by some melting glacier-that the truth can be inconvenient.1 We have reason to know, from our encounters with television (TV) if not other aspects of our daily routine, that truth can be rather discomforting at times as well. And finally, when we want and need it most, truth can have the vexing tendency to prove somewhat elusive-at least for a while. Like the arc of the moral universe,2 the arc of information bending ultimately toward truth may prove quite long. One's patience is tried.


These considerations converge, in what was recently made infamous fashion, in the delivery of medical guidance on TV. The infamy derives nominally from an article in the British Medical Journal (BMJ),3 and more so from the reactions to it,4 purporting to characterize the veracity of recommendations delivered by doctors on medical programs, namely, The Dr. Oz Show and The Doctors.


This is, in fact, a matter germane to both the management and practice of public health. If there are to be standards governing the flow and reliability of health-related information in our culture at large, they must derive from efforts in public health management and related policy. If health literacy,5 and attendant empowerment, is to be cultivated at the population level, it must account for competing sources of attention, and discern and apply effective means of communication and engagement. This is fodder for public health practice. Metaphorically, we must understand when our charge is to fill empty vessels; when vessels filled with misinformation must first be artfully drained; and how to make our own salutary libation most palatable. And so it is that medical information on TV that matters to the viewers, matters to us.


The fundamental conclusion reached by the BMJ researchers was that evidence was available to support specific recommendations made on the popular medical shows-whether by the hosts or by their guests-only about half of the time. This, and other details in the article, engendered a good deal of hyperbolic press,6 and rather vitriolic responses from the BMJ readers, alleging that the hosts of medical TV shows were, in essence, charlatans.4


The BMJ authors themselves, however, have vigorously rebutted any such assertions based on their work.4 For one thing, some of the entries on the list of TV recommendations would hardly invite a randomized clinical trial (RCT), such as advice to block the transmission of a sneeze by aiming it at your elbow; the recommendation to get rest and fluids if you have the flu; or the tip to avoid outdoor activity when pollen counts are soaring if you have seasonal allergies. Yes, apparently these were among the 160 "recommendations" reviewed for the BMJ, and they serve only to remind of the adage: absence of evidence is not evidence of absence. Public health practitioners also propagate such guidance, if a product more of sense than science.


We have no way of knowing how many other recommendations were of this ilk, since the inventory was not published. The authors do note, however, that often the TV recommendations were quite generic and may even have distilled down to consult about this with your health care professional. To my knowledge, there has been no RCT to prove that consulting with health care professionals about, for instance, how best to use the results of RCTs, changes outcomes, but it does seem plausible just the same.


Summing this argument up, I am inclined to note now as I have before7 that if my foot were to catch on fire, I would not need data from an RCT to fetch a pail of water. Were public health practice to be predicated only on data from such trials, Snow would never have removed that pump handle,8 and many other worthy efforts would be much forestalled.


The BMJ authors go on to acknowledge in their response to letters that the liabilities of medical recommendations are not unique to TV. Citing publications in the Archives of Internal Medicine9 and the Journal of the American Medical Association,10 they concede that "some" evidence is available to support only about 3 of 4 recommendations made routinely in clinical practice; "good" evidence is available to support only about half of the recommendations in official medical guidelines; and RCT data are available to support only about 1 in 10 clinical recommendations.


This suggests that even if the expectations of TV were entirely concordant with those of clinical practice, the prevailing standards would prove more confluent than otherwise. But as the BMJ authors themselves do, again in their response to letters rather than in their original article, we may constructively ask: are the expectations concordant? Why, in fact, do millions tune in for medical advice on TV?


To my knowledge, that study has not been done; the researchers among us might consider that an invitation. In the interim, we are left once again to informed conjecture in the absence of good data. Personally, I think the motivations overlap substantially with those for patient-centered, holistic, integrative care.11 First, as we hear from some rather prominent sources, today's hurried, harried doctors may neither listen well12 nor fake it convincingly. TV doctors may not be listening to every viewer, but they effectively convey the empathy that is all too often lacking from clinical encounters in the real world. Millions apparently yearn for it, and that is not inconsequential. This, too, is an invitation and provocation to public health practice. We are challenged to show that public health is about deeply personal connections and admonished to make people not merely know it is true but feel it.13


Second, as already noted, RCT data are often lacking for even routine medical guidance and action. There are none, for instance, to prove that stopping the hemorrhage from a bullet hole is better than letting it bleed, but candidates for a randomized trial on this topic are understandably hard to recruit. Sometimes, we are obligated to do the obvious thing-for individual patients and populations alike.


Such data are lacking as well, and far more often, for highly personalized clinical guidance in the context of intricate, challenging medical and social circumstances. Patients routinely turn to holistically inclined practitioners to get help in just such context; they may turn to TV for the same reason. Patient need goes on, alas, long after reliable RCT data run out, particularly for those unfortunate souls who have conditions not currently well understood. Someday, for instance, specific perturbations of the microbiome may be definable and fixable to ameliorate bowel irritability. For now, however, it is a "syndrome," lacking any reliable diagnostic test, and to some extent the respect garnered by a more fully defined "disease."


When medical need is unaddressed by a clinician who says some variant on the theme of-"sorry, no data, can't help you"-it will impel a patient to seek elsewhere. Effective, engaging, and empathetic public health programming can help fill this void. So, apparently, do doctors on TV.


Perhaps, doctors on TV are more inclined than those in clinics to admit that medical advice is, of necessity, a product of sense as well as science. We simply don't have the science to answer all relevant questions, some of them quite urgent. Perhaps, millions tuning in for medical help on TV is something of a referendum on modern medical practice, and if so, the vote is less than flattering. This, too, is a provocation to the health care system as we have devised it and thus public health.


The TV audience may also recognize, as the angry BMJ letter writers apparently do not, that the playing field of opportunity to generate medical evidence is far from level. Nearly a decade and a half ago, for instance, in the aftermath of a very small, very short clinical trial, the "final nail" was declared to have been driven into the coffin of the coenzyme Q10 for heart failure hypothesis.14 At almost that same time, a study orders of magnitude larger and years longer confirmed the utility of the proprietary drug, carvedilol, for the same condition.15 All these years later, we finally have evidence to prove that coenzyme Q10, a compound found in almost all plant foods, can reduce heart failure mortality, astonishingly, by nearly 50%, when superimposed on best current therapy.16


What accounts for this historical odyssey of evidence is all about money. Carvedilol was protected by a patent; coenzyme Q10 is in every stalk of parsley. When the costs of bringing a new Food and Drug Administration-approved drug to market approximate a billion dollars, intellectual property protection is all but required to allow for a return that can justify such an investment. As some have noted, therefore, we may have far more money-based than evidence-based medicine.17


In this context, the attention of the BMJ authors to the matter of conflicts of interest is almost ironic. They note that TV doctors and their guests often fail to disclose real or potential conflicts on air, although stipulations by which such programming is governed bound such matters rather stringently.18 They are quite right that this is important but fail to juxtapose this concern to its counterpart in clinical practice, where drug company profits exert an enormous, insidious influence on clinical recommendations19 and propagate conflicts of interest that are virtually never disclosed. Yes, money exerts an influence on TV programming and surely everyone knows that. It exerts an influence, if at times quite clandestinely, on clinical practice, too-and that is likely far less known.


While I have ostensibly come to unbury medical TV, I have not come particularly to praise it. I have witnessed excesses and have misgivings. A question that should have been probed by the BMJ authors but was not-why do people seek medical advice on TV in the first place?-is fundamental to this examination.


I have worked for TV and know well the mantra that guides news programming behind the scenes: comfort the afflicted, afflict the comfortable. TV news in general gyrates between the two, generating a disequilibrium that cultivates our need for the next installment, and the next. Medical programming is much about the former, comfort for the afflicted. When losing weight, finding health, relieving pain, or sleeping well prove impossibly difficult-a perky, optimistic, entertaining segment on TV may make each feel possible again.


There are both potential benefit and real risk in such programming. The benefit is the legitimate empowerment of patients to seek, and find, solutions otherwise overlooked and underutilized. The risk is the propagation of false hope. In navigating between these, hyperbole is a constant peril. The envelope of edutainment is rather elastic, and the imperative for ratings, the prod of producers, and the requirement to be quite entertaining all no doubt quite compelling. Still, doctors on TV are doctors and the oaths they have taken prevail. There are lines they must not cross. Those of us in public health patrol those lines. We also foster health literacy, ambient levels of which should be sufficient to immunize viewers against the notion that TV doctors, whatever their charisma, are any more likely to have graduated Hogwarts than the rest of us.


The viewers are their own first line of defense, which, in turn, leads to the most famous of all caveats: caveat emptor. In the application of TV medical advice, as in so much else, when we meet the enemy-it may prove to be us. To some extent, it may be us individually, as we hope to hear on TV some shiny new promise that sounds too good to be true. We tune in eager to suspend our critical appraisals, born of common sense and routine experience, just as we do when shopping for some book offering the next effortless way to lose weight, find health, or stop the clock. The suspended animation of common sense, of course, is as ill-advised when seeking medical counsel as when shopping for a bridge.


But to an even greater extent, it is us collectively, at the level of culture. We deliver to our medical programming a dual, and all but delusional, verdict: a rebuke for excesses20 and an Emmy award for excellence.21


And so we return to where we began, with the inconvenience of truth. Medical evidence is merely means to an end, that end being knowledge of what is true. But medical evidence is at times absent when thought present22; present when thought absent16; inscrutably subject to internecine debate23; or repeatedly wrong over time in every conceivable direction.24 More often than not, medical guidance is informed by neither absolute evidence of effect nor its absence but by a relative absence of directly relevant evidence and the need for informed judgment. This is where the science of medicine ineluctably collides with art and where the need for empathy takes hold.


The inconvenient truth about medical evidence, with which we are all afflicted, is that we often lack what we need. The discomforting truth about medical TV is that its imperatives derive from both education and entertainment. The truth about truth is that it is often elusive.


And so a reality check about medical TV is warranted. So, too, though, is a reality check about that reality check and the operational realities of clinical practice. Truths prove elusive, inconvenient, and a bit uncomfortable. In all directions, there is cause for less hyperbole, more humility.


The perils of tuning in to TV for medical insights deserve attention, but they too are subject to perilous distortions. The worry is that TV doctors may be pitching dubious medicine. We in public health must remain vigilant to ensure it is not so. But in an age of rushed clinical encounters, hyperspecialization, and doctors who need to be reminded to listen at all, TV doctors-earnest, empathetic, hopeful-are not necessarily pitching medicine. The truth with which we all need to grapple may be as much about embracing humanism as avoiding hyperbole. Perhaps, they are the medicine.




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