Monday, November 02, 2009

Marcia Angell on the corruption of physician expertise

I missed this Jan 2009 quote when it came out. I tracked it down after reading a post Jacob Reider shared (emphases mine, I remember that she was the Editor in NEJM's glory days) ...
Drug Companies & Doctors: A Story of Corruption - The New York Review of Books - Marcia Angell

... The problems I've discussed are not limited to psychiatry, although they reach their most florid form there. Similar conflicts of interest and biases exist in virtually every field of medicine, particularly those that rely heavily on drugs or devices. It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.

One result of the pervasive bias is that physicians learn to practice a very drug-intensive style of medicine. Even when changes in lifestyle would be more effective, doctors and their patients often believe that for every ailment and discontent there is a drug. Physicians are also led to believe that the newest, most expensive brand-name drugs are superior to older drugs or generics, even though there is seldom any evidence to that effect because sponsors do not usually compare their drugs with older drugs at equivalent doses. In addition, physicians, swayed by prestigious medical school faculty, learn to prescribe drugs for off-label uses without good evidence of effectiveness...
I've been long away from the world of practice, but my recollection is that there were very good thinkers on groups like the US Preventive Services Task Force. On the other hand, confident experts ruled the big panels, and they were as predicted, often confidently wrong. (The American Cancer Society was infamous for this, but lately they've surprised.)

Angell may be too harsh, but the reversals of the past ten years (estrogen therapy being only one) should humble all physicians. I'd suggest starting with humility and seeing where we go.

See also:

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