I’m going to whack the scientific and medical communities in this post, so let’s start with a big point. Science is a lot like Winston Churchill’s observation about democracy. Paraphrasing him, democracy is the worst form of government except compared to every other form of government ever tried. To complete the analogy, science is the worst form of human knowing except for every other form tried. Thus, science is generally a good thing, but it ain’t perfect because it’s still people who are doing it. Thus, while it is a good idea to look for science when possible, you shouldn’t stop thinking simply because some science exists on a topic.
The latest evidence for the combination of science plus skepticism comes from the howling we hear from the medical community about the effects of hormone replacement therapy. Let’s quote a recent news story:
“U.S. breast cancer rates plunged an unprecedented 7 percent in 2003, the year after millions of women stopped taking menopause hormones when a study showed the pills raise the risk of tumors.
The startling new analysis, reported Thursday at the San Antonio Breast Cancer Symposium, does not prove a link between hormone therapy and breast cancer, but strongly suggests it, many experts said.
“When I saw it, I couldn’t believe it,” statistician Donald Berry of the University of Texas M.D. Anderson Cancer Center in Houston said of the drop.”
Sounds like great news, doesn’t it? Picture the scene . . . stunned medical researchers and physicians staring with slack jaws at bar charts showing the greatest single year decline in breast cancer cases ever recorded. Somebody must have discovered the greatest pill since aspirin. Except the decline isn’t caused by people taking a pill but rather from people not taking a pill. Not taking a pill all these slack jawed marvels thought was the greatest pill since aspirin just a few years ago. Turns out all the science they were sure you could find behind HRT didn’t exist. Too bad no one did that science before they prescribed it to millions of women.
That quote about . . . “does not prove a link between hormone therapy and breast cancer, but strongly suggests it . . .” is a bit odd in this context. Looking at some of the strongest scientific evidence anyone can produce in this field, Experts are skeptical about drawing causal links between the decrease in HRT use and the decrease in breast cancer cases. A few years ago when everyone had a pill to push and had considerably less scientific evidence about the potential harms of HRT, nary a peep of scientific skepticism was heard. Everyone just knew without having to do the science that HRT was safe and effective.
If you’re trained as a scientist you can go to Medline, the National Institutes of Health’s online medical library, and do your own key word searches on HRT and discover for yourself just how weak the science at that time was. If you’re not trained as a scientist, one compelling piece of information you can easily confirm with your own physician is to ask if HRT was an “off-label” prescription. Off-label means that the physician is prescribing the pill beyond the scientific evidence for that problem. In other words, the physician didn’t use direct evidence, but rather drew inferences and made assumptions. Thousands of MDs went off-label with HRT and prescribed it knowing that there was no direct scientific evidence for its safety or effectiveness. They just assumed it because of the existing science from other applications. And millions of women took those pills like good little girls without realizing they were participating in one of the largest natural drug tests ever done in the history of medical science.
Quick replay: thousands of medical scientists and physicians use science and conclude that HRT is safe and effective, but then when they go “off-label” and wisely assume that HRT is safe and effective past the basic research, tens of thousands of excess breast cancer cases emerge and then when everyone goes off “off-label” breast cancers case drop in the largest reduction ever seen. Isn’t “science” supposed to be the royal road to truth? Let’s finish the way we started. Science is the worst form of human knowing except for every other form tried. Clearly, even scientists have trouble always doing science.
It’s also interesting to look at how people are reacting to all of this from a persuasion perspective. Scientists are people too and subject to the same rules as we all are. Scientists freely chose a behavior (recommend HRT for menopausal women) without good science behind that behavior. Then, it turns out that the behavior leads to negative consequences. That is the classic path to dissonance. Now, when dissonance is elicited, people are motivated to get rid of it. How do you get rid of dissonance? Well, the classic path here comes from Attribution Theory. When you freely chose to do something that leads to a negative consequence, you can avoid dissonance with an external attribution. “You know why I did that? I did it because Something Else made me do it.” (For the oldest literate demonstration of this please consult Persuasion in Literature and Adam, Eve, the serpent, and the apple.)
Okay, thousands of women got breast cancer at least prematurely and possibly needlessly because they took pills off label as prescribed by their physicians. There’s got to be a bad guy here and anybody who’s been following American health care can tell you who the first likely suspect will be: the drug companies. Hey, they made the pill. They made the physicians prescribe it. They made billions of dollars in profit. They are the bad guys!!!!
In the interest of full disclosure let me note that I was a paid consultant to one drug company in 2002 while I was a scientific administrator in the CDC. (You can imagine the paperwork that I had to complete to get that clearance.) Over one weekend I met with about 20 other Experts to discuss the problem of medical compliance. Believe it or not, up to 50% of people do not properly take their prescribed medical regimen. This panel was convened by the drug company to come up with new ideas for motivating people to follow all the instructions all the time, especially with drug use. It was a great trip held in San Juan during the winter. I brought Melanie along and she had a great time, so I had a great time, too. Plus, it was interesting working with all these other Experts in a wide variety of fields. The drug company did an excellent job of squeezing ideas out of the best minds they could find and, as these things go, at a fairly cheap price. If they got even one good practical idea out of this gang, it could potentially be worth millions of dollars in sales and profit to them. They did not pay us anywhere near the potential value. I have also been a paid consultant with a variety of medical practice and research groups over the years so I’ve been bought off by that side of the street, too. I’m filled with biases from my past as an academic, government administrator, and consultant. And in the interests of even more disclosure, I have close relationships with women who’ve had breast cancer following HRT. It’s a tangled web. Okay, so it’s disclosed and now you know my hidden agenda in this. Back to the disaster . . .
More HRT use caused more breast cancer. The drug companies made HRT, sold it, and profited from it. So, thinking the way the medical community reasoned years ago about the potential benefit of HRT, it’s obvious the drug companies must be the bad guys here. While writing this post, I did a quick Google search (terms: off label hormone replacement therapy) and found several websites already pointing digital fingers (there’s a cute irony, “digital fingers”). Please check out either this post at the Columbia Journalism Review and another from a blogging physician. Both identify those bad drug company boys and girls as culprits. Yes, I’m wildly overgeneralizing from one case to the whole population (as if CJR speaks for all journalists). I’ll take my chances that my inferences about how journalists and physicians view this and take a big leap with the assumption that they mostly agree: The Pharmas Did It!
Okay. Without any exception, exemption, or excuse, the pharmas own a large slice from the pie of guilt baked up in this disaster. They did promote the pills. Relentlessly. Effectively. Cleverly. They followed the advice from Blake in “Glengarry Glen Ross,” Always Be Closing and that’s what the pharmas did.
But, so did journalists and so did physicians. To hear the CJR try and wash clean the dirty hands of American media here is beyond my ability to restrain laughter during “American Idol.” Journalists in print, radio, and electronic outlets did no, none, zero, zed, zip, nada “investigative reporting” on HRT even though the weak research record was easily available and understandable. Journalists, too, are driven for the bottom line and Always Be Closing is just a standard part of corporate journalism. They didn’t look because it was too easy to just report what they heard and it was too profitable to report what they heard.
And, physicians. The one blog post is hardly representative of the group. I’ve spoken on a personal basis with a few physicians and they will all point to pharmas as a source, but they will never accept any responsibility for their own off-label prescriptions. They will point their fingers at pharmas even though none of those pills could have been taken if the physicians hadn’t written the script for it. And if MDs are so weak of character that the bad boy pharmas can literally and legally make them write script against their better judgment, then what kind of judgment do MDs really possess? Apparently, the kind of judgment that can be bought and sold rather easily. Wouldn’t it be wiser for the AMA to stand up quickly and take this one on the chin. Yep, we were wrong. We didn’t do our due diligence with the science on this one. We’re not sure exactly how much of the blame is ours, but it’s big enough to warrant our acknowledgement. But that declaration would mean a lot of dissonance and dissonance ain’t fun.
There will probably be a train wreck in some American court rooms over this. Pharmas will write a big check, but I don’t think that physicians will escape unharmed financially or reputationally. Journalists will have a great time with this story. They will act indignant with everyone and send out swarms of investigative reporters who will get to the bottom of it all the same way Woodward and Bernstein did with Watergate: They’ll read court documents publicly available and act as if they risked their lives like you see in a Hollywood movie.
And all this is predictable, explainable, and possible through understanding the persuasion concepts of dissonance and attribution. Maybe . . . there’s certainly more going on and not every person involved can be understood this easily or simply. But, the ideas do apply, have merit, and make sense within these limits.
This is a long and complex post, so let’s summarize. Science is great for knowing, but sometimes it fails largely because scientists are people and they fail. And, these failures can be understood through persuasion concepts. Like I saw all this coming, right? Of course, not.