Factually! with Adam Conover - When Modern Medicine is Wrong, Evidence-Based Care, and Trusting Our Doctors with Dr. Vinay Prasad

Episode Date: October 9, 2019

Hematologist-oncologist, author and evidence-based medicine expert Vinay Prasad MD MPH, joins Adam this week to talk about medical reversals, the addiction of helping someone while making money, decision-making with suboptimal evidence, what questions to ask your doctor, and much more. This episode is brought to you by Acuity (www.acuityscheduling.com/factually). Learn more about your ad choices. Visit megaphone.fm/adchoices See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

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So if all of that sounds good, if you want a big box of delicious snacks like this for yourself, use the code factually for $15 off your first order at Bokksu.com. That's code factually for $15 off your first order on Bokksu.com. I don't know the way. I don't know what to think. I don't know what to say. Yeah, but that's alright. Yeah, that's okay. I don't know anything. Hello, welcome to Factually, I'm Adam Conover, and look, we believe that medicine is a scientifically backed, evidence-based field, right? We trust, we assume, we at least hope that every procedure or medication we're prescribed has been rigorously tested by a battalion of federal agencies and a phalanx of scientists. That every doctor we visit never sees their kids because they spend their weekends reading medical journals.

And that rigorous, evidence-based approach means that we can trust medicine to fix what ails us, for instance, back pain. 80% of adults experience back pain at some point. And since that pain can be debilitating and lasting, most of those people are probably turning to modern medicine to do something about it. And for decades, a common treatment for lower back pain was a surgery called spinal fusion. In spinal fusion, two vertebraes are joined together or fused to stop them from moving against each other. Now, that's pretty intuitive, right? If movement between two vertebrae is causing the back pain, then stopping that movement and turning them into one super vertebrae should ease the pain.

Easy peasy. Well, it's no wonder that spinal fusion caught on like surgically sterilized hotcakes. There was just one problem. Spinal fusion doesn't actually work. And we've known that since the early 2000s. A review of four trials found that spinal fusion was no better than non-surgical options for chronic back pain, stuff like supervised exercise. And some patients who go through with spinal fusion actually end up with even more pain than they had before. But despite the clear evidence against the effectiveness of this procedure, during the 2000s, spinal fusion only became more popular, with rates more than doubling in the U.S. during that decade.

And that runs deeply counter to the assumption we have about medicine always being responsive to science, right? Because even though we knew, as a matter of science, that this procedure didn't work any better than non-invasive exerciser therapy, doctors continued to prescribe completely unnecessary surgery that involved cutting open your back and messing around with the bones in there for no good reason. What is less scientific than that? And spinal fusion is far from the only medical procedure doctors have prescribed, even though we know it didn't work. Similar results have been found in surgery to repair torn meniscus in people with knee pain or stenting in people with heart conditions. In fact, new clinical trials often reveal that common medical practices or procedures used by doctors on actual patients like you or me never really worked. When this happens, it's called a medical reversal.

And it's far more common than we'd like to think. The truth is, doctors are not titans of reason who always obey the dictates of the scientific method. They're people who make decisions for sometimes irrational reasons. And while medicine as it's practiced in America today does strive to be scientific and usually succeeds at that, it's also a bureaucracy with competing interests, and it's an industry, one of the largest on earth, to the tune of $3.5 trillion in 2017. And a giant money-making boat like that can be hard to turn, even when science says it should. In this gigantic system, it is no wonder that the best science doesn't always win or that institutional change can lag behind evidence. Well, the work of our guest today highlights just how large that gap

between medicine and science can be. Dr. Vinay Prasad is a hematologist, oncologist, and associate professor of medicine at Oregon Health and Science University. He's authored 200 academic articles and is the co-author of the book, Ending Medical Reversal. Please welcome Dr. Vinay Prasad. Hey Vinay, thank you so much for coming on the show. Oh, thank you so much for having me, Adam. It's a pleasure to be here. So look, as I talked about in the intro, we have this assumption that when we go to our doctor, we are receiving evidence-based care, that every procedure, every diagnosis they give us is based on the best available medical science. Maybe that's not entirely true, though. To what extent is it not true? And to what

extent should we be worried about it? I guess what I'd say is right off the bat, I think that's that's that's the same assumption I had when I was a medical student just starting out. I went into medicine with the assumption that, you know, the doctor offers you a service, there probably is good reason why they're offering that to you. That probably been proven to work in well-done studies. And it was sometime during my medical training that I started to see examples where that wasn't the case, where we were recommending things that turned out to have very weak evidence and some things that had been contradicted by the best evidence. And so the answer to the question in terms of, can you actually try to estimate, you know, of all the things doctors do, how much are really well supported by evidence,

and how many things have been contradicted, and how many things are kind of uncertain? And the answer to that question is a sort of a project that was done many years ago by the British Medical Journal, where they kind of picked 3000 random medical practices. These were things that were randomly chosen from the hundreds of thousands of things doctors do. And they said, if we looked up all these 3000 things, what would you find? And what they found was that maybe about a quarter or a third of things were really well supported by the best available evidence. And there's a fraction of things, maybe about 15% that were contradicted that we knew probably didn't work, but we're doing them anyway.

But there was 50% of practices, so sort of the bulk of practices, we just didn't know one way or the other. There was no credible evidence. And I think that was kind of a sobering result. And that led us to do some kind of follow-up work on that. And how concerned should we be about that? I mean, 50% not being, we don't really know one way or the other, whether it's not supported. Well, now these are probably practices that doctors have been doing for a while and they have anecdotal or sort of, you know, casual evidence that they work. Hey, nobody's getting particularly sued. And the doctors might tell you, well, all right, I certainly see recovery in my patients

when I prescribe this and I've seen thousands of people. And so that's why I do it. So it's sort of maybe customary practices. That doesn't sound like something we should dismiss out of hand, or should we have more concern than that? No, I think you're putting it really nicely. I guess I'd say one way is to look at the broad arc of history. If you look at medicine as it's been practiced for the last 2,000 years, we're lucky to live at a time where it's only 50% of what we're doing that we have no idea about, right? Because for most of history, it probably was the majority or perhaps everything we were doing, we had no idea. And you're absolutely right to say that just because we don't know it works, doesn't mean

that it doesn't work. There probably are some of those practices that do work, that would be validated. Yeah. But there are also probably some of those practices that wouldn't work and that aren't validated. And we've done a lot of research to kind of tease that apart. What would that 50% look like if you subjected it to, like, rigorous testing? So, like, when we're talking about – I really like that comparison to medicine in the past because there's all the sort of, like, you know, we know about these procedures that were, you know, we make fun of them today, right? And some of them hold up and some of them don't. People always make fun of leeches, but I know that leeches actually had a lot of benefit,

right? In terms of preventing, I believe, preventing blood clots and things like that. But then also, you know, the sort of four humors theory of the body, right? With phlegm and those sorts of things where, you know, people would do bloodletting as a therapy. Some of them were good, and some of them were bad. And some of those, there are probably some practices today that, you know, we haven't investigated that hold up, but some that don't, and we all want to know which ones don't, right? Yeah, I guess I'd say, you know, like an example of leeches, probably of all the things we did bloodletting for, probably the majority of those things were wrong. And, you know, we might have accidentally hastened the death of some people like, for instance, George

Washington. But for people with maybe hemochromatosis, bloodletting was always the right thing to do. You know, so, so, you know, a broken watch is right twice a day. And so, you know, so even some of these debunked practices maybe they had a tiny role but i guess what makes this modern sort of um you know iteration of you know what i call medical reversals so compelling is that many of these practices they they weren't adopted in the 1920s they weren't adopted in the 1800s some of these practices were adopted just five or six years ago presumably in the era when we should have known better. And yet we're still adopting practices that turn out not to work.

And why does that still happen? Well, so, yeah, help me out with that question. I talked about in the intro about spinal fusion, which is a procedure for back pain that, you know, the amount that it was prescribed, the number of people receiving it was going up, going up, going up. the amount that it was prescribed, the number of people receiving it was going up, going up, going up, even after we had strong evidence that it didn't work better than non-surgical interventions, which seems to fly in the face of not just science, but, you know, smart people just looking at the results, right? I would imagine, hey, a doctor can read a medical journal as well as anybody else and see that this doesn't work. So why do these procedures persist and even grow, even though there isn't evidence or evidence proving that it doesn't work?

Yeah, that's a great question. And I guess I'd say that the answer is probably many things sort of converging on this question. One of the things that converges here is that doctors are trained in, we come from a tradition of if it makes sense, it probably should work. So much of our education is about the mechanistic understanding of the body, physiology, biochemistry. We're taught about the body from a very small level. And we come to make a lot of clinical decisions based on our best understanding of models that drive the body. So we approach medicine, not perhaps in a statistical and probabilistic way, probably more in a sort of mechanistic way. And that leads us to be seduced by practices that make sense.

I think the next thing is all human beings, it's probably our best characteristic, but we suffer from excessive optimism. We think that what we have thought of is really gonna change a disease that's been having a burden on humanity for thousands of years, millennia. And we think we have finally have the solution.

Optimism is great. It's what encourages people to take risks and try new things. But it also has to be kind of checked with realistic appraisal of evidence. And then the last factor I would quote to you is, I think the elephant in the room is that a lot of providers make a great deal of money from doing certain sorts of interventions. In America, we heavily reward people who do procedures and surgeries and place devices. doctor, probably the most sort of mentally addictive thing for a doctor is if you do something for someone that you really believe is benefiting them and you receive a financial reward on top of that. That's the methamphetamine of being a physician. That's a highly addictive

substance when those two things come together. And I think once you become addicted to doing something that you think should work and you're making money doing it, somebody comes along and they tell you that, you know, this new study says it doesn't work. And physicians are very smart. And this has been shown over and over again. Smart people are very good at coming up with reasons why the new study doesn't apply to what they're doing. What I'm doing is different than the new study. The new study is flawed. You didn't look at patients like the patients in my clinic. I'm somehow, you somehow exceptional, and your study doesn't apply to me. And so smart people will always find things that are wrong with these studies. But I always point out to them, you produce a study that's better. You show me on paper where this is working. Don't just tell me this new study is bad.

Show me how this treatment works. Show me a positive study. And that often is something that they cannot do because for many of these practices, there are no positive studies. Well, so what you're talking about is like a combination of very natural biases and incentives and influences that in many cases, I think could come to a positive result. Like the fact that, you know, a doctor has a general understanding of how the human body works, sort of the same way that a car mechanic knows how a car works. So they can come up with their own theory and say, Hey, yeah, makes sense. Those two vertebrae are running, rubbing up against each other, causing the pain. Let's fuse them together. Makes sense to me based on my understanding of the, of the body. Well, that's a good way to work.

Most of the time, I would imagine that helps you get to a lot of right results. Absolutely right. You're absolutely right. Which is that, you know, trying to come up with a model for how the body works and thinking of things that might fix a problem that leads to a lot of right answers, too. Yeah, but it also leads to a lot of wrong answers. So how do you separate the right answers from the wrong answers? And the solution is you have to do you have to do the kind of study you have to do a well have to do the kind of study, you have to do a well done randomized control trial, which, you know, I'm happy to talk about what that means. But you have to do the kind of study a skeptic would do. I think you have to develop products

like a believer, but you have to test them like a skeptic. And we develop products like a believer, but then we test them like a believer, which means we don't do the right test that might contradict our assumptions and hypotheses. And so how can the average person, though, like work with this information? Like, for instance, I'll give you an example. A year or two ago, there were articles ping ponging around about how flossing doesn't work, that dentists have been telling us to floss forever and there's no studies on flossing. And here's one study that says that flossing doesn't work. Uh, that dentists have been telling us to floss forever and there's no studies on flossing. And here's one study that says that flossing doesn't work. People were emailing me these articles saying, Hey, Adam, you should do this on your show. Right. And my general feeling

about medical topics that we do on our show is I want to be very conservative about which ones we take because I don't want to want to ever give bad medical advice, but you know, it did stick with me as like, okay, this holds up interesting. You know, that is an interesting narrative that, yeah, hey, we've all been flossing out of habit. Dentists have just been telling us to do it because they're used to doing it and there's no other reason. So when I went to see my dentist, I asked him about this study and he said, oh no, no, no, no, no. This study is terrible. You know, all of us dentists are making fun of how bad it is. It's very bad information. No, no, you should definitely still floss. You should definitely still floss.

And I'll be honest, over the last year, I've been going back and forth on flossing. As a result of this, I'm like, I'm not really sure if it's good works or not. The main reason I'm doing it is because when I smell the floss after I do it, this floss is stinky and I'm like, maybe it's making my breath smell better. But I don't have a way of really evaluating. I can go read the study, but I'm not a scientist, right? I'm not a, I'm not a medical scientist, certainly. So I could do my best to pick it apart, but I don't believe I'm an expert. And you know, there's a, I'm getting contradictory information here. So how do we, how do we think about that? Those sorts of results? Yeah, that, I think that's a great question. So I guess I'd say,

let me just talk about your floss example. At the risk of getting on the bad side of big floss, I guess I'd say I recently looked at the evidence. And so one of the places, when you ask me about floss, and I'll be honest with you, I'm a cancer doctor. Floss is not something that's on my radar in my day-to to day practice of medicine. OK, but, you know, I see people discussing floss and I'm kind of curious myself, just like you're a curious person. And so I want to know what's the answer. So I like to the first thing I look for is, OK, is there sort of a meta analysis, a study of kind of all of the studies? And there are some outlets that do really credible kind of meta analyses. And one of them is something called the Cochrane Collaboration.

It's been doing it for decades now. And I recently pulled the Cochrane Collaboration's report on flossing. And they said we were able to find so many studies that looked at floss versus alternatives. And their bottom line was they concluded that the evidence base was super, super weak. And they didn't actually make a strong recommendation. And that's probably because floss is like one of those things that is extremely compelling. It seems like it should make sense. If you get more gunk out of your mouth after you eat and before you go to sleep, it's probably a good thing overall. But the definitive studies would be to kind of test

flossing versus other strategies and watch people over time to see if they develop gingivitis and cavities and plaque and plaque and erosion to see see if they develop gingivitis and cavities and plaque and plaque and and animal erosion to see and you could actually blind people and see is the breath of the people who floss better than people's breath who don't floss you can do all these kinds of studies there probably honestly is not a lot of interest in doing those studies but you're asking a better question which is you know what can the average person do and i guess i would say there are so many things in in our day to day life, that we will all have to make decisions with a suboptimal evidence, for instance, whether or not to drink, you know, how many cups of coffee

is right to drink a day, whether or not to eat blueberries, how many times to go to the movies a month, right, you're not going to get a good study for all these things, you got to make your you got to make these choices in the absence of those studies. And I think that's okay. I feel comfortable doing that. But when you're in the doctor's office and the doctor is talking about prescribing you a costly, potentially toxic medication, they're talking about implanting a device in you, I think that's when you have to start asking really tough questions for the doctor. And I think the questions you should ask are, what evidence do you have that taking this

pill or having this device will make someone like me better off? Can you point me to that study? And I think the classic way in which patients get misled is they get kind of sidetracked into a conversation about how should this drug work? Like, how might this drug work in my body? And they get sidetracked into the mechanism. They might watch a video online of, you know, sort of a magical device being put in and all of a sudden, you know, someone's hip pain goes away,

but they should instead gravitate towards the nuts and bolts, which isn't how it works, but what is the proof that it works? I think it's a very different question. Yeah, and we've talked about on our show before about how the, you know, that image that you see, for instance, in a commercial of the drug entering the body and the red areas being soothed into blue areas, or that little

capsule description is incredibly convincing to us. Like we'll latch onto that, even though that might be based on almost nothing. Exactly right. I mean, anyone can make a computer graphic showing that the red areas turn to blue areas and it looks good. But what is the proof that drug helps? And you raise another interesting point, which is, you know, there are only two nations on this planet where you can have direct to consumer advertising of prescription drugs and prescription products. And that's the United States and New Zealand and everywhere else in the in the world, they think that this kind of advertising is inappropriate because it only leads to kind of misleading inferences about how well these products work. And these are products that require the gatekeeper of a physician you

know and trust. So I think we should have a broader conversation about whether or not this advertisement really helps the public. Well, so let's talk about some more examples of this sort of process happening. On our show, in a year or two past, we covered mammograms, which was, frankly, the topic that we were the most careful about in our entire history on the show, because we thought it was really interesting and fascinating and compelling, but we did not want to give bad medical advice. So we had Dr. Joanne Elmore on the show, who, you know, is a expert in this particular field, really walked us through how we should think about it. And the conclusion that we came to and that the medical establishment is coming to is that mammograms are less effective than we thought and can lead to

harms if not used judiciously. Does that sound accurate? Sounds absolutely accurate. Okay. And, but that's a very difficult point to get across because people are very frightened of cancer, justifiably. A lot of people have stories about, you know, I had breast cancer and the mammogram caught it. And, you know, my life is, they believe their life has been saved by the mammogram. But, you know, the evidence is pretty clear. And it's also clear of other, for other cancer treatments, such as PSA tests and things like that. So what do we do when a practice is so entrenched like that, right? Everybody's been told for decades, they should go get their mammograms. They should go get their cancer screenings. Early detection is the key. And now we're sort of finding out, well, actually early detection can lead to more

false positives, which leads to harms. And then we sort of need to turn that massive boat around. And it sort of violates an emotional truth a lot of people have, which is that these tests help. What do we do about that? You're putting this so nicely. I think you're hitting the nail on the head. But I mean, I think you're really hitting the nail on the head, which is that there's an emotional context to some of these medical decisions, and it's very difficult to get around that. You know, let's just talk about the mammography issue. We shouldn't forget that it was not that long ago, the US American Cancer Society put out an ad and the advertisement said, if a woman hasn't had a mammogram, she needs more than her breasts examined, implying that she was crazy. Yeah, you know, so this, you know, so much of cancer screening came at a time where advertisements

made it seem like this is not a decision. is not a discussion this is something that either you do or you're a crazy person who wants to risk their life you know that's that was the way was portrayed moving from that cultural point to a point where we can kind of have an honest discussion that these are screening tests that might have potential benefits and they also have certain downsides and certain harms that's been very very difficult and the other point you make which I think is a really good point, which is that a lot of people in this society have had a cancer that was found through screening, and they had a surgery, and they feel as if their life was saved. But there's a number of well-done studies

that show that might not be the case. Because if you if you, you might have found a cancer that would otherwise not have caused a problem in the rest of your natural life. That's something called overdiagnosis. You also might have found a cancer that a few years later was destined to spread. Had you not found it, it came back no matter what that you found it early, and you caught it and you had a surgery, but it still came back. And in that case, all you've done is kind of added to the amount of time you're a cancer patient, but you might not have changed the inevitable outcome. You didn't really, you know, catch it before it spread. And so they're both of those kinds of problems that make cancer screening very, very difficult. I think mammographic screening is one of the hottest,

you know, most heated topics that are in medicine. There's so much uncertainty and there's so much and there's strong opinions on, I think, both sides of the spectrum. So what can the average person do? I think the average person who's thinking about this decision, I guess one thing I would say, is they should start with an organization called the USPSTF, United States Preventive Services Task Force. This is an impartial group that makes a recommendation. And I think their most recent recommendation is for women between the ages of 40 and 50. They should have a conversation with their doctor about the pros and cons of this for them. And women between the ages of 50 and 69 should undergo this no more frequently than every two

years. And so I think the USPSTF is a good starting point for I think what's reasonable. But even once you look at that, I think then you have to have a conversation with your doctor. And I think you have to do a little bit more and try to at least understand what is the point of view of both sides of people on this issue? Why are there people out there who are unlikely to do this? And why are there people out there who think it should be done, you know, all the time for everyone over the age of 40? What are their, you know, what is the debate? And, you know, it's like anything else in this modern world. There are political debates on all sorts of issues. If you want to be an informed citizen, you got to

know both sides of the issue and then decide what's right for you and where you fall. Yeah. It is rough though, to ask the average person to be up to date on the debate within the medical community on a particular procedure. When, I mean, again, like you rough, though, to ask the average person to be up to date on the debate within the medical community on a particular procedure. When I mean, again, like you don't even you said it yourself. You're you're a doctor and you're not up to date on flossing or you got yourself up to date, but it wasn't part of your your daily regimen. And when it's everything from flossing to breast cancer, it can be a little bit overwhelming. be a little bit overwhelming. But let me say, I think the, to me, the way it looks from the outside, the change that we're seeing with mammograms actually seems pretty positive because, hey, we had these screenings, we were overusing them. Now there's a course correction

that it seems like a large amount of the medical community is on board with. We're changing the recommendations. This is an official government recommendation to reduce the screenings a little bit in order to reduce over overdiagnosis and harms. And that almost seems like, hey, this is how it's supposed to work. You got to make those adjustments. But let's talk about the situations where, you know, the healthcare industry is getting involved, where, as you said, people, you know, doctors are making their living on procedures that we know should not be done. How does that happen? Do you have any examples of that in our current medical practice?

Yeah, but I mean, I guess I want to come, I just want to touch on one of the things you're saying there, which is that, I think you're 100% right, which is that this course correction is a good thing. It's a good thing for society. It actually empowers people in a way that generations before us, we've not been empowered, that we understand that there are pros and cons to

screening. But you asked another question, which is, is this the way it should have gone? And that question is a question that I struggle with a little bit, because maybe it could have gone differently. Here's how it might have gone differently. What if before we deployed these screening tests, be it mammography or PSA screening? What if at the outset before we had a society invested in the screening test? What if that was the moment we decided to do the definitive studies? And then he said, you know, and so here's a good example. There are a number of companies right now that are pursuing a blood based screening test for cancer. This is called the Holy Grail. And in fact, one of the companies is, I think, named Grail,

because after this Holy Grail. A Holy Grail test. What would a Holy Grail test look like? Anybody would go into the doctor and get a blood test every year. And then one year, the doctor would say, oh my God, I'm seeing a signal, maybe pancreatic cancer. Let's go take a look. We might find some early cancer precursor,

get a little surgery, cut it out. And suddenly, we've saved a life from pancreatic cancer. That's the, you know, that's the golden idea. And there are a number of companies working on this problem. And, and I guess what I want to say is, when should they be allowed to sell these products on the market? And people who do the kind of work I do, who do evidence-based medicine, we tend to believe that they should do, they should be allowed to sell their product after they've proven that using their product year after year saves lives when compared against people who are not using their product, who aren't getting the blood test.

But all of the commercial forces in medicine want to lower that bar for approval. Some people want to say, it should just be enough that we find a protein signature that's linked to cancer. I don't need to prove to you I save lives. We can assume that. And the more you assume, I think the more you run the risk that decades from now, future generations will look back and say, you know, we really got out of control with that blood test. We were ordering it on people in whom it was totally inappropriate. And we probably should have only done it in a certain age group or for people with certain risk factors. You know, these are the kinds of things so i guess what i'd say the lesson of

mammography and psa screening is in part a positive lesson we've made progress but it's in part a learning lesson which is that once you launch a large-scale screening program in the population the horse is out of the barn people will be wedded to it for generations and so you got to make sure at the outset you get it right. And these blood-based screening companies, I think people have to hold them to a high standard before we adopt it. Can I also ask you, what you're describing sounds like a recipe for over-diagnosis and over-treatment. And yeah, the harm, just to make it vivid to people, is that someone gets these tests, it's a false positive, and they then believe they have cancer, which is a harm for someone to believe that they have cancer when they don't. They tell their family, everyone cries,

they're depressed. That's really bad. And then maybe they get treatment they don't need. They get surgery they don't need or some other form of procedure. And those procedures have risks. And, you know, maybe those people suffer an adverse health outcome because of, you know, they got an infection during a surgery or something like that. So these are real harms that we're talking about with overdiagnosis. A lot of people think, oh, the more, you know, hey, I don't care if it's a false positive, the more information, the better. And like, no, you really should care about that. And we should certainly care about it when we're talking about a whole population. I have to say, though, I'm seeing companies that are advertising, you know, currently genetic screening for cancer

that, oh, hey, swab the inside of your mouth and send it in with your 23andMe. And we'll tell you that you're a native American, if that's something you want to believe about yourself. And also we'll tell you about your cancer risk. Um, and, uh, I'm a little bit, when I see those claims, I'm a little bit skeptical. Do you have any opinion about these sort of consumer genetic testings for cancer and other diseases? Yeah, I guess it's a huge and thorny issue. And there's lots of pitfalls. I guess I'll say a few things. One, you know, when you send off these genetic tests to this company, you swab the cheek and you send it off. First of all, let's be honest, half the things they tell you are things you know, if you look in the mirror, your earlobe is detached and your skin color and your hair color. I'm probably

of Indian ancestry. Okay, thanks for that. You blew my mind there. Half the things are telling you very obvious things, but they do tell you some things about maybe your risk of Alzheimer's disease, maybe your risk of a certain, one of the classic things that has been marketed so far is the BRCA genes, the breast cancer related cancer genes. And I guess there's a number of pitfalls. So one of the first, you know, we wrote a paper that came out in the Journal of American Medical Association about one of the companies that was selling a direct to consumer test for this breast cancer mutation. It turns out that mutation is very, it is a common mutation in people of an Ashkenazi Jewish ancestry. But among all people with the deleterious mutations in BRCA, it is not the most common.

It's actually just a tiny bit. So there's also the risk that you will take this test. You'll find that you have a family history of breast cancer. You take the commercial test. You find you are not a mutant. You feel reassured, but you actually do have a bad genetic risk factor. So I guess I'd say that I think it's a bit of a Pandora's box situation when you have, you know, a bad genetic risk factor. So I guess I'd say that I think it's a bit of a Pandora's box situation when you have, I think, commercial companies direct to consumer

testing without a genetic counselor in the middle who can kind of ask you about your history, think about what test to order, order the right test, and then counsel you about what to do about it. And there's a really nice article I think came out a few weeks ago about somebody who got found out that she had a cancer, a genetic cancer, genetic risk syndrome. And and there was no counseling. It just got dropped in her lap. And she had to sort of deal with that. And I think it's a very difficult position we put people in. So I guess I'd say there's a lot of you know, there's a lot of uncertainty there. And I would recommend somebody who has a family history of cancer, go to a genetic counselor, let the genetic counselor tell you what the right test is.

I have a real concern. We're getting a little bit off topic, but I do really want to make this point that I have a concern about these genetic tests that they're giving people genetic information when the public doesn't actually understand genetics that well. And I think that's true, both of medical issues and of race, that people are shown a pie chart and they think they understand something when like the degree to which race is a part of genetics is so vague and complex and requires like the input of experts. But people look at the pie chart and say, oh, I'm 15% that. Oh, turns out I'm 2% Siberian. Wow wow i guess i must have a great great great in siberia somewhere when that's not how genetics works so i think there's a real risk to giving

people sort of this raw information willy-nilly and letting them come to their own conclusions i think having a counselor is a good idea but so let's talk again about um let's come back to you know the uh let's follow the money a little bit, like, like that, that influence that you're talking about, how does that show up? And do you have any examples in which it does? I guess, one of the examples that I think there's going to be some cardiologists out there who are probably not going to like to hear this as an example, but it is a great example, which is that one of the things we do in this country for people who have a heart attack is place a flexible metal expanding stent in the artery that has a heart attack. We open up the

blood clot. And if you're having a heart attack and you get that stent placed, it's an absolutely life-saving intervention. It has a huge survival benefit. Dick Cheney has like 50 of these, right? Dick Cheney, I think he's got the, he's had many. He's had a long history of heart problems. But now I guess he has a new heart. So presumably they've been removed with the old heart. New heart now. But on the other end of the spectrum, we have a lot of people who have something called chronic stable angina. This is chest pain that comes on where you might be exerting yourself and at the same amount of exertion, you kind of feel this chest tightness. You sit down and take it easy. It gets better. Chronic stable angina is

a very common cause of exertional chest pain. It's chronic. It's there for a long period of time. It's stable. It doesn't get a lot worse over time. It's sort of reproducible. Every time you put out the same exertion, you get the same pain. There are many people with chronic stable angina who also undergo stent placement. Some surveys from about a decade ago suggested that it was even like 60, 70, 80% of people getting stents were getting it for this reason. These are a very expensive procedure. It's an invasive procedure. We have to puncture an artery and put a guide wire into the heart. And why would you have this procedure done if you have stable angina? So one of the reasons you'd have it done is if doing the stenting would lower the risk of a subsequent heart attack or improve your survival, that would be a good reason to have it done. But we've known since 2007 in a randomized trial called COURAGE that this stenting procedure does neither of those two things. It doesn't lower the rate of subsequent heart attack, and it doesn't improve your longevity.

And yet there have been a number of studies of patients undergoing the procedure. If you ask a patient who's about to get it done, what do you think this procedure is for? A sizable percentage of those patients will tell you, oh, this is to lower the rate of a heart attack and increase my longevity. So patients undergoing the procedure are under a misconception of why they're doing it. Then the next part of the story is that, well, does it improve the anginal symptoms? And for a long time, we believed it improved anginal symptoms. But in 2017, there was a study called Orbita that kind of put that on its head. So this was a study where people went to get the stenting procedure done. And they wore headphones like the headphones you and I are wearing. And the doctor was doing a procedure. And in half the patients, they did the stenting. And in the other half, they told the patients they stented them, but they didn't

actually do the stenting. Wow. That's a proper control. Yeah. Proper control. And the measurement, the primary endpoint of that study was exercise time on a treadmill. And so if you think that stenting open these arteries is making someone feel better, you should have improved exercise time. But the provocative finding of the Orbita study was that exercise time was not significantly improved. And so I think Orbita puts, you know, the whole idea of stenting these lesions on its head. Now, a lot of cardiologists will say, well, Orbita is just one study. There are limitations like any one study. And that's true, although it's a really well-done study.

And the limitations, I think, have been overstated. But on the flip side, if I ask somebody who does this all the time, can you show me a positive study where you've randomized people to the placebo procedure and stenting and you have a symptomatic improvement? And the answer is there are zero positive studies. There's only one study and it's negative and that's Orbita. And so I think the burden of proof has to be on people who believe this works to show it works. And you talk about money. This is something where we are in the midst of sort of a cultural war.

People who do this, they make sizable income. We're talking about income in excess of $10 billion in the U.S. annual, maybe even $20 billion. For that one procedure? Yeah, across all the population of people who get it done. Wow. So we're talking about tens of billions of dollars. Yeah. And so when there's money at stake of this magnitude, I think there's going to be a lot of resistance to to changing guidelines.

And I encourage anyone who believes that this intervention really does make people feel better to prove under what circumstances people feel better. So to do a sham control, placebo controlled study like this and prove that people feel better and then we can have, I think, a more honest discussion about it. Then we can have, I think, a more honest discussion about it. But this is the – I'm going to butcher the quotation, and I forget who said it, but it's the difficulty of making someone see the truth when their salary depends on them not seeing it, right? It's that classic problem. Exactly right, yeah. I think that's an Upton Sinclair quote, yeah. I think it is.

Yeah. No, I think you're right. It's difficult, and that's in part because we are human beings. And so I think when you, you know, the people who do this procedure, I don't want to make it seem as if they're only doing it for the money. I believe that they genuinely believe that they're making their patients feel better. And in fact, in the Orbitus study, people in both groups, whether you are getting the procedure or the placebo procedure, they both felt better than before the intervention. It was just that there's no difference between the two of them. So there is a placebo effect of having this done. And in a doctor's office, when you're a doctor and you're treating people one at a time, patients may come to you after the procedure and say, thank you, doctor, I feel better. And years of hearing that kind of make

you come to believe that it works. But you, of course, are not an impartial observer and you're not doing a controlled study in your practice. So sometimes I think experience can be misleading. It's sort of it's been a truth of medicine since the era of Hippocrates. It's still true today. The experience of one doctor practicing can be deeply misleading. You need to do these kinds of studies so you can overcome the limitations of your own senses. Fascinating. Well, I have so many more questions for you, but we have to take a quick break.

We'll be right back with more Vinay Prasad. Okay, we're back. So man, a lot of doctors must hate your guts, right? Is this, have you made some enemies in your community? I guess I'd say that there are also many, many fans you probably would also make out. I'm sure there are. I'm not trying to make you sound like the most hated guy. I mean, walk me through how you came to this work, right? Because you're a little

bit unique as being a doctor who's so outspoken about this issue. What's your background and what brought you here? Well, I'll tell you that in a second, but I guess I'll tell you like there are, you know, it's funny that you pick cancer screening as one of the first things to talk about because I'll tell you what, cancer screening is one of those topics that you're going to get a big backlash on both directions. You know, that's something that's just constantly controversial. And genomics is the other one. That's another topic I get my in-basket fills up with. But a lot of these things, you know, are kind of boring technical things that I think a

lot of people don't get so heated about. I would also add one little caveat here, which is that if you're a doctor and you're, you know, I think an impartial and honest doctor, you shouldn't be so attached to any one procedure or pill or device. You should not feel an emotional response if somebody tells you a pill or device or procedure is wrong. It's not about you. It's about the procedure. So I do hope people separate it. But, you know, you asked the question, how did I get into this work?

you asked the question, how did I get into this work? Well, I think in the beginning of this podcast, you said like what the average person might think about medicine, which is that, you know, when doctors say do something, they probably have good reasons to say it. That's exactly how I was when I was a third year medical student. I did two years of classwork. I started on the third year and I was 100% right there. I was, if the doctor says do it, it must really work. Sometime in my third year of training, I had a couple of people, you know, ask me to look up the evidence for, of all things, mammography for women between the ages of 40 and 50. For some of the procedures we were recommending to patients, some of the pills they were on in the hospital. some of the pills they were on in the hospital. And every time I came back from doing one of those like, you know, mini presentations in the hospital, I came back with a lot more uncertainty. I came back with that sort of naive optimism kind of slowly going away. I found out that,

you know, the data for a lot of these things wasn't that great. For some things, I thought the best data suggested that this shouldn't be offered or maybe doesn't make a whole lot of sense. And so I think that was the moment in my mind where I started, decided that I want to think about these things more. As a physician, I want to recommend things that I have 100% confidence in. And I want to be honest when I don't have that confidence and work with someone to decide how much uncertainty they're willing to accept. And so then when I went out of my training, I was an internal medicine resident in Chicago, and I worked with a really great professor named Adam Sifu. And together, we wrote a book about these kinds of topics called Ending Medical Reversal. And Adam was also a physician who

spends a great deal of time sort of thinking and agonizing about these decisions and about this evidence. And so maybe this was a little bit over a decade ago now. That was sort of the moment that I got interested in it. But I didn't know it would kind of become a career topic. There are not a whole lot of doctors who do this kind of work. And so I had assumed I was just going to be a practicing doctor. But it was only maybe after publishing so many papers on this topic that I kind of felt like there was a momentum and to run with it. Do you still practice as well?

Yeah, I am in clinic. In fact, for the purpose of this podcast, I've had to take a break from my clinic today. Oh my gosh, I'm so sorry. No, we were able to... A lot of people in your waiting room will try to make the rest of this quick. No, we had a lot of advance notice, so it was a few months ago. But I'm in clinic a couple days a week, and I spend a couple months a year on service. And I guess one of the nice things about my job is a lot of the times I see patients, I do so with people who are training.

So students, residents, fellows, people who are training to be the full physician. And that also keeps you incredibly humble. There is nobody better than somebody who is totally new to a topic to ask you a question that you take for granted, that you realize that you really don't know the answer to, and that makes you hit the books at night. Right. It's that beginner's mind approach of looking at it for the first time. How does that inform, how does your perspective on medical reversal inform your practice in ways that maybe you operate in the examining room or, or when you're prescribing things differently from other doctors?

I guess I'd say the, the number one way it impacts me is, um, to spend, uh, a lot of time, um, really having an honest discussion with somebody. You know, I think there's so many things in medicine, like in life, where we have to make decisions to do something or not to do something. And we don't always have the luxury of having the perfect study or the perfect evidence. And I think that might be okay. But your job as a doctor is to explain all of that uncertainty explain the best studies to the person in the room with you and and make sure they actually understand it so just take the time to hear them say it back to you so that you feel as if they understand it and then allow them to make

the right choice for them and so what i spend so much of my practice trying to do and i don't i don't claim to be the best at this but it it's something I aspire to be good at, which is to allow people to make choices that are most congruent with what they want if they knew everything I knew. And so I think that means that a doctor lives up to the Latin meaning of the word, which is teacher, which is where the word comes from. So you become a teacher of sorts. And I think that's how it shapes me. The other thing it shapes me is when I read the newspaper and I hear about a game changer, revolution, miracle, or cure that's right around the corner, I know better than to believe those articles.

And I read those articles with a very critical lens. And then I go on Twitter and I say what I don't like about it. So those are, I think, the two ways it changes you as a person. I also think – I just want to add one more thing. You might find interesting. You know, when you learn medicine and you read something like people pick up the textbook of medicine, but a textbook of medicine is like a history book. History is written by the victors. When you read a textbook of medicine, it makes it seem as if everything we do in 2019 was a logical, inexorable progression from things that came

before. That's how history books are written. But history books don't include all of the false starts, the blind alleys, the missteps. The medical textbook doesn't have all that in it. And it can't because it'll be like 4,000 pages. And to be honest, not everyone reads it anyway. Okay, so no one's going to read it if it had all that. But so that's what I think this work has really given me, which is that I spend a lot of time reading about the history of things that we don't do anymore, that we used to do. And when you read about this history, you read that very bright people at the best hospitals who were super smart, and probably honestly motivated, they all were seduced by these practices. And then you come to realize that, you know what, am I really better than all these

people who came before me? And probably not. And so I have a lot more humility with which I approach medicine, because I realized that many, many smart people in the 60s, 70s and 80s were misled, and they did things that were wrong. And I have to be vigilant so that I am not one of those people 20 years from now. I love that so much. That's the drama I'm constantly banging that we always need to be questioning what we think we know. And that that's the first step to actually learning more and to actually understanding the world is to doubt ourselves and doubt our common practice. And yeah, if you never have an education on the things that we did wrong in the past, if you never learn about the four humors and bloodletting, you will not know what the equivalent things we are doing today. You won't

be looking out for them. I want to go back to the, I want to go back to the media though. How does the media and especially the way that these new discoveries get reported, how does that contribute to this problem? Well, I guess in so many ways, but I guess,

I mean, the first thing I want to say is that, you know, I guess, I mean, what you said reminds me of the quote that he who forgets history is condemned to repeat it. And I think we see that a lot in medicine. But about this about this problem, I think what I think about is first, let's just look at the media coverage of health care.

Right off the bat, a huge chunk of media coverage of health care is something called nutritional epidemiology. These are stories about how many blueberries should you eat, whether or not you should eat dark chocolate tea. And I think it's fascinating to me that these studies get so much inordinate, disproportionate news coverage when the quality of these studies is super, super low. And they are known to continually flip flop on these issues. And I joke with when I give lectures to students, I joke that if you do a study on a pitted fruit, you can put that in the trash can. Peaches and plums, you can go to hell. But berries, you're going to be in the newspaper. Coffee, tea, dark chocolate, red wine.

This is catnip for the newspaper. I mean, these certain certain types of food, not even all foods. They love these red wine stories. They love dark chocolate. They love green tea. It drives me crazy. These are the lowest credibility stories and they fill a huge chunk of the media narrative. And so the average person out there who reads the health news, no wonder they get so disillusioned because

one week coffee was good for you. The next week it's bad. Eggs are good for you. Not bad. So I wish we would just give up covering these, but obviously they're clickbait and people want to click on it. And we had a professor on our first year who, you know, as an experiment published a hoax study. And, you know, I'm not frankly, you know, hoaxes are a little bit dodgy of a way to make a point, you know. But I think he made the point quite well that, you know, he published a very poor study in a one of those pay for publishing journals and then sent out a press release. And it got pickup in a number of places even though it was complete bullshit. So it's, you know, the level of rigor in the news media,

especially about will chocolate cure cancer is so low. It's unbelievable. Yeah. Like these people would be, they'd be fired from the national desk if they wrote that about politics or about foreign policy. But when it's in the health section, apparently that's – you're able to just publish outright fiction. Oh, now you're making a really astute point.

So the other thing I wanted to say was, okay, so that's – part of it is the nutritional problem. But then there are also good stories, good topics, good drugs, good devices. One of the problems we often see when they pick a good topic is one source stories. So it's a press release from a university that says, you know, we have a miracle treatment for breast cancer. But what they only interview people who are working on the project, there's no second source. And as you point out, if you're in politics doing a one source news story, and it's the sources, you know, there's no confirmatory source, you're not going to last. I mean, that's not the standard of journalism. But in health, I think the standard is lower.

And there's this whole idea of churnalism where basically newspapers just churn, they just churn the press release. It's a churnalism mindset. Right. And you just see the same quotes, the same people over and over again. I think another problem in the news is the fact that when you have a new study and you want to quote on that, you need somebody who is a non-conflicted person, somebody who's not being paid by the company whose product is being discussed. It seems obvious to me, but we often see conflicted people giving quotes about the newest Genentech drug or AstraZeneca drug,

and they're consulting for the company. And that doesn't put you in a very impartial position. But I also want to say that I think the healthcare media does a lot of things right for, you know, the people who are doing a bad job, they get they get a lot of attention. But there are some of the best journalists I've ever met who are health journalists who are super smart, maybe as smart as scientists, I know, and they ask the right questions. And we you know, when you see their name in the byline, you can trust that article. And so, you know, so there's a range like in anything else. Do you have any particularly, just let me ask, trusted sources for health news where you're like, hey, the reporters there really, really do do their good diligence? I guess I've been, I mean, I, that's a good question. I guess

I'd say there used to be a website called Health News Reviews, and they used to review news from a whole bunch of healthcare sources, and they consistently offered really good, high-clarity results. been sort of a big fan of some of the stories that come out of FiveThirtyEight and Vox, who've done a really wonderful job of covering health and science news, not just specific topics, but some of the broader sort of systematic problems. And there's some really great stories about nutritional, the problems of nutritional science media on these websites. So I think journalism is kicking it to the next level, kind of doing these sort of umbrella reviews of health journalism itself. Yeah, I do start to see more reporters saying, you know, using the word meta-analysis and taking a

look at the studies and, you know, using that process to actually try to figure out what's true and what isn't. I want to touch on, you said you understand why people get disillusioned when they hear this in the news. And I think that is my biggest concern in this conversation, because so much of the time, the advice that I want to give, say, as a communicator who's talking about these issues with people, when we're talking about mammograms, when we're talking about the difference between, you know, wellness treatments that are placebos and, you know, medical treatments, we want to say, hey, talk to your doctor, trust your doctor. You know, we say in our episode where we talk about the placebo effect,

we say, hey, there's no problem getting a placebo-based treatment because those can actually make you feel better as long as you go talk to an actual doctor as well, you know, try to cure your cancer with acupuncture, right? So I want to be able to give that advice. And at the same time, I feel bad when I hear people getting too cynical about medicine. You know, when someone says, ah, the doctors are just trying to run up the bill by giving you treatments you don't need. My reaction is to say,

no, no, no, these are the experts. Like, we should really default to trusting them. At the same time, we've just spent about 45 minutes talking about all these phenomena where, hey, sometimes that actually is happening in a way. And we do need to be skeptical, but we are not experts as we, the patients, will never be experts. So where does that leave us? I mean, I don't want people to leave this conversation and now be very cynical when they go to their doctor the next time. But how should they feel instead? No, such a great question, which is, I think what you're getting at is we have to acknowledge a few things. Are there some problems in medical science that we ought to improve upon as a profession? Absolutely. At the same time,

in this country, in this moment, we live in a time where there is a vocal, fervent, strong anti-science and anti-medicine sentiment. And the last thing anyone should walk away from with this conversation is that all of medicine is bad. All of science is flawed. Everything is flawed. I don't have to believe anything the doctor says. That's the worst takeaway message. And there are, in fact, I think some shameless profiteers who want you to believe that. They are wrong. Science and medicine is the best thing that's ever happened to human beings. It's the best path forward. The problems in medicine should be healed with a scalpel and not a sword. They need to be understood and corrected, but you don't throw away the whole thing. And I think that's the challenge here.

I do, as you can imagine, I get emails from people say, yeah, everything the cancer doctor says is wrong. I say, oh, boy, that is totally no, no, there are a lot of things that are really beneficial, and that really work. But you have to empower yourself to know what it is you what is being prescribed to you? What are your odds with or without a treatment? How much does it help you? Is it worth the side effects, cost and inconvenience to you? I mean, I think you have to be your own best advocate. And the last thing you want to do is throw the whole thing away. And the other worst thing to do is ignore the problem. So there's something in between. Life is complicated. There's nuance, which I think you've done a great job of kind of fleshing out. And that's a hard

thing. You know, I once read a quote that said, the funny thing about really understanding something is you become less and less confident while people who don't understand it all, they have no doubt at all. And I think that's the problem in medicine, which is that when you really, really understand something, you don't have a strong and polarized view of it. You have a very nuanced view. And there are people who do the work I do. Our goal is not to, I think, dump on medicine. It's not to criticize the field. It's to really try to push us to get better.

There are things that we could do to get better. I would like that to happen in the lifetime that I practice medicine. And so I don't want to wait. And that's why I do this work. That's really wonderful work. And I honestly thank you for doing it. I think that's a wonderful place to leave it unless there's anywhere else, anything else you want to cover in this or any message you have to patients the next time that they go to their doctor with a serious complaint, just what

should they have in mind? I guess I would say this is a shameless plug, but, you know, we spent a lot of time writing this book, Ending Medical Reversal. And what we try to do in this book is take you through some of the history that people forget, examples of things we thought would work that didn't work. And at the end of the book, we have a supplement of nearly 200 examples of things that don't work. And there's a chapter in that book where we say, what should the patient do when they go to the doctor's office? And I think that – I do think, that's a good starting point. That's a place people can look if they're interested in this conversation. You seem pretty optimistic about this overall, that, you know, despite these, I mean, look, the American healthcare system has so many systemic issues. We haven't even talked about

cost in this conversation. And obviously, that is the most salient issue with American healthcare. But we've talked about all these systemic problems that are leading to procedures that we shouldn't be doing that are harming people, etc. But you really seem to feel that the progress marches forward and that we can correct these issues. Is that the case? Yeah, I guess I do believe that in medicine and in many things in life, that the arc of history bends towards progress. And we may stutter and stop and take a few steps backwards. But we are a whole lot better today than we were 200 years ago. And we will be better in 200 years. And I think that so I am optimistic in the long haul,

that reason prevails and that science will get it right and that people will be better off. And I hope that I and I and I. Yeah. And so I think we'll go in that direction. Well, I thank you so much for fighting that battle and for coming on today to talk to us about it. This has been an awesome conversation. Thank you so much. Yeah. Thanks for having me. It's a pleasure. Well, thank you once again to Dr. Vinay Prasad for coming on the show. I hope you enjoyed that conversation as much as I did. His book, once again, is called Ending Medical Reversal.

And that is it for us this week on Factually. I've been Adam Conover. I want to thank our producer, Dana Wickens, our researcher, Sam Roudman, and Andrew WK for our theme song, I Don't Know Anything. You can find me on Twitter at Adam Conover. You can follow me on Twitch sometimes if you want to watch me stream video games. I do that on occasion. Also, Adam Conover.

And go to adamconover.net to sign up for my mailing list. And until next week, we'll see you on Factually. Thanks so much for listening. That was a HateGum Podcast.