Dishonesty in Medicine. This comes in many forms.
One of my favorite quotes from Shakespeare is " a man can smile and smile and be a villain still". It is maybe self-evident but dishonesty generally arises because the perpetrator gets some benefit from it, and the benefit is generally financial, but often is as simple as self-validation that they are a doctor and are important and know better.
I had meant to write this blog, and I may follow up with writing that one, on describing what appeared in the scientific news that researchers in a university in the North East US fabricated animal data, and this included (which I find a dark humor to it): publishing an image that they had already published some 5 years ago, and said this was a new image on a current study. But that report of dishonest fabrication was reported some months back.
I am writing this present blog, because a medical colleague brought to my attention an article that Kalsey Piper wrote in Vox on a cardiologist Don Poldermans from the Netherlands (with a sigh of relief this time it was not the US or Canada) that reported beta blockers are useful prior to cardiac surgery. A meta-analysis in 2014 showed that giving beta blockers resulted in a greater likelihood of death within 30 days following cardiac surgery. The doctor confessed that some/much of his data was fabricated, AKA lies.
The estimation is that 800,000 thousand deaths likely occurred due to this fabrication.
To start with the long view of dishonesty in Medicine: there are two larging intersecting circles of dishonesty: research and clinical practice. The common forms of dishonesty in Research include: deliberate fraud; lack of knowledge; and incompetence/sloppiness, in descending order of severity. In clinical practice: lack of knowledge, incompetence (age-related, alcohol-overuse, drug use); masquerading as a physician, fraud, and deliberate harm, in descending order of frequency. I include here malpractice as a form of dishonesty that relates to the above listings.
In considering the topic of dishonesty/malpractice, it has been reported by a couple of sources that medical error is the fourth most common cause of death in the US (and I assume the developed world). Medical error is likely greater per doctor contact in the developing world, but there are so many other causes of death even greater in significance : infection, starvation, malnutrition, and war in developing countries.
Not having studied the data in depth I suspect most of these deaths in the data on fourth leading cause, are atleast partially excusable, too high or too low a drug dose in someone who is elderly and likely to die within 6 months anyways. But at the same time, I suspect it is also under-reported and under-included deaths that should be avoidable, such as higher maternal mortality in black women. My intuition and experience informs me that the deaths most covered up are deaths in young to middle aged women- individuals who otherwise did not have a short life expectancy. A more detailed discussion will be in a future blog.
There are several truths about dishonesty in Medicine:
Probably the most common underlying cause is the general paternalistic tendency of physicians to 'know it all', when in fact they don't, and may not know essentially anything about that particular subject they expound on. Relating this to my area of expertise, GDD, the majority of these paternalistic physicians would not necessarily derive financial benefit from this. Within this category, and I think it may still be the majority, are formal trained radiologists, neurologists, etc who think that if your kidneys are normal, and you did not experience acute hypersensitivity reaction, then you can't be sick from Gd (GDD), and you are simply nuts. These health care workers, and maybe I am too lenient (well too lenient for those who are vicious to patients about their denial), I employ the words of Jesus on the cross: "forgive them for they know not what they are doing".
I use GDD just because it is the subject I am most familiar with. This applies to many different aspects of health care, drugs etc. That is also why I instruct everyone " you are the steward of your own health care", but the caveat is you have to have wisdom-sense.
The second group of physicians is smaller, and they do not know the truth, but derive financial benefit from it. Radiologists who want to keep patient throughput high in imaging studies, or don't want to lose revenue. I would say they could know the truth... after all I wrote most of my articles in major journals, and a quick search on PubMed or even Google would take them there. It is difficult to tease out between how many of them are just plain being lazy ignorant and not keeping up with the literature (which they should know because it is in their field), or show willful ignorance. So this is not clearly evil, but it may be still that Dante would place them in the first circle of Hell.
The third group are the ones I have great issue with. They do know better, but for financial gain (such as financial support from companies to give talks or to do marginal value research, sometimes phony research) or may be just the prestige in being invited to give talks, they say things they know not to be true. I would put them in the mid range of Dante's Hell, maybe the 4th circle, with the gluttons, hoarders, and squanderers.
The majority of cases where physicians have been held responsible for patient harm or death, have been individual cases of direct physician-patient mistreatment. In the case of patient death, they have been charged with at least manslaughter. It is time that physicians who have willfully injured a great number of patients, either directly, as for example being drunk and operating, or indirectly, by knowingly promulgating false information, be held fully responsible. Currently the only physicians who have been held to account in this fashion are those that have sexually molested women, by unnecessary or too lengthy vaginal examination. The poster perpetrator being Larry Nassar. I am fully prepared to be an expert against physician perpetrators and the administrators who cover them up, to arrest this practice. This may be the least understood and most . covered up malpractices, especially the role of administrators and their accomplices. Large financial and prison penalties, even with a few perpetrators, would go a great distance in diminishing this critical dishonesty/ malpractice A case like Poldermans may be just such an example for future prosecutions. I am particularly keen at going after institutions that have knowingly allowed doctors to operate drunk.
The vast majority of individuals who speak about safety, in basically anything, but certainly medicine, are not making any money from it. In the Capitalist system money comes from doing more and not doing less. I coined the expression, back in around the year 2000 when I was focused on CT, medical radiation, and cancer death from medical radiation: "there is no money in safety" which is still true today. Generally, standing up and speaking about safety is a dangerous pursuit. A politician recently observed cowardice is rewarded, courage is punished. This I know from personal experience is almost always correct.
So an estimate is made that 800,000 deaths could be contributed to this misinformation of Dr Poldermans. I think he was fired, but suffered no further repercussions.. But what should happen to people like this? Should he be treated like a mass-murderer: Jack the Ripper I think killed only 6 women, maybe he killed up to 20. The Golden State mass-murdered killed 100 or so women. Mass-murders in the US often get sentenced with the death penalty, which I am a huge believer of. The death count associated with Poldermans is getting into the territory of Hitler. But by extension ofcourse what about the deaths of innocent civilians in an unprovoked war? But to return to Medicine.
In my mind the concept seems reasonable that a Beta Blocker would be a good thing to use in advance of cardiac surgery to keep the heart rate low and blood pressure low. So we can understand how many, many physicians fell into this dangerous misconception. In many respects this points to the critical importance of other groups showing similar findings, or if they have dramatically different findings the reporting of this has to be accelerated. Ironically I think often when research goes against the orthodoxy of current medical practice, it is very difficult to get published. I have written in excess of 360 peer-reviewed articles (in excess of 540 of all types of written articles, not including blogs), a number going against orthodoxy, so I am very familiar personally with this. Was his intention therefore to kill people? I would have to say no. But he must have been so blinded by money from the companies making these drugs and the fame that he was receiving, that he felt the rules no longer applied to him - he knew better. A perversion in thought that is all too common.
What I was dealing with in my research on CT and cancer risk from medical radiation has echoes of this. Researchers,( and not myself, most true scientific experts on medical radiation risk, I am not in that number) in the years 2000- 2010 reported that the deaths from cancer in patients due to undergoing CT were in the range of 30 thousand annually, from an estimate of around 20 to 30 million CTs being performed. If we add up 20 years or so of this, that brings us to 600,000, which is not far off Poldermans numbers.
What is critical though, and there are some positives. The response of CT companies was to modify their systems with the end-result intent of delivering less x-radiation. This started with decreasing the amount of x-radiation from CT in children.
It would ofcourse be nice if changes in practice to accommodate safety should be done much faster- not requiring 10 years of clinical experience to get to this point of understanding. Accelerating publications on safety would facilitate this.
This does make me think that there should be a category of physicians who would be considered in some respect 'national treasures', like poets or artists, who focus their career on safety, and their salaries paid for by the government. Because very often, the consideration of safety not only benefits patients themselves, but also national expenditures. Most of the time safety also translates into less money spent on unnecessary, and not uncommonly dangerous, medicine. I will address in a future blog on my thoughts on the United States Preventive Services Task Force.
Protector Publicus
Richard Semelka, MD
Opmerkingen