Is advertising by doctors and hospitals worthwhile?

The decline of medicine as a profession began when it became legal for doctors and hospitals to advertise.

Apparently it all started when an Arizona lawyer sued for his first amendment right to advertise his services. In 1977, the US Supreme Court ruled that states could not prohibit advertising by lawyers.

This opened the floodgates for all professionals. Soon advertising by doctors and hospitals became common.

I don't know what it's like where you are, but I can't listen to the radio without being bombarded by doctors advertising their wares like car dealers and ads for bogus "university" hospitals.

Outrageous claims are made. The best, the most advanced, the newest, the latest, the most experienced, the most talented, and many, many more.

Just like car dealers, every hospital in my area is "#1" in something or other. Often more than one hospital is #1 in the same specialty.

Here's a sobering number. In the first half of 2011, hospitals in the US spent $717 million on advertising. This is despite the consensus that hospital advertising has not been shown to be effective at generating business. In fact, hospital CEOs admit that much of their advertising is aimed at stroking the egos of their doctors or boosting staff morale.

Regarding advertising by doctors, I don't know if that works either.

When I was in private practice in the late 1970s and early 1980s, advertising by physicians was mostly limited to the telephone book's Yellow Pages [younger readers may be excused for a minute to google the term].

Every patient who ever came to me via the Yellow Pages either didn't pay his bill, was non-compliant or both. Apparently, only a certain type of individual chooses his surgeon via the Yellow Pages.

I eventually stopped listing myself in the Yellow Pages.

In addition to wasting a lot of money, hospital and physician advertising is harmful because it creates unrealistic expectations among patients. A case in point is the ongoing debate about the supposed, but yet unproven benefits of robotic surgery. The ad below appeared in an airline in-flight magazine. Do you think it is effective? Do you believe it?

Although there is no proof that robotic surgery results in better outcomes than traditional laparoscopic techniques, hospitals have marketed robotic surgery by having potential customers play with the robot in such places as shopping malls and minor league baseball stadiums. [For a comprehensive look at robotic surgery advertising by hospitals, check out the Health News Review blog here and here.]

The public is flooded with advertisements promising miracles that often cannot be delivered. Disappointment surely follows

Is this the only reason for the medical profession's fall from grace? Of course not, but it certainly hasn't helped.

If advertising by hospitals and doctors disappeared tomorrow, we would all be better off.

CEO of Surgical Robot Maker “Spins” References to Favor His Product

In an interview on a website called MassDevice, Gary Guthart, CEO of Intuitive Surgical, maker of the Da Vinci surgical robot, offers many seemingly persuasive arguments regarding why the robot is revolutionizing modern surgery.

Here is an example of an interesting answer he gave to a question about a paper from the Journal of Clinical Oncology that said robotic hysterectomy was much more expensive than standard laparoscopic hysterectomy without demonstrable improvement in outcomes. Guthart said, “It turns out that the paper actually entirely misses the point, in that it compares laporoscopic [sic] to robotics, but the reality is that what's happening in the market is robotics are converting open procedures to robotic procedures.” 

The paper didn't miss the point at all. It made the point that standard laparoscopic surgery is equal to robotic hysterectomy except for its cost.

He went on to cite a paper in European Urology [full text here] that he said: “covers 20,000 minimally invasive prostatectomy surgeries – almost all of which are robotic – and it covers 60,000 open patients. What it shows is that a length of stay for the minimally invasive arm is reduced by 2 days and that complications – basically every complication they measure – are less with robotic than open and mortality is significantly less with robotics than open.”

The paper was a study of a Medicare administrative database and compared 19,594 minimally invasive radical prostatectomies [MIRP] to 58,638 open radical retropubic prostatectomies.

The word “robot” is mentioned only six times in the paper, mostly in the context of this sentence from the “Methods” section: “A unique designation for robotic assistance did not exist during the study period; therefore, we were unable to distinguish pure laparoscopic from robot-assisted surgery, and both were categorized as MIRP.”

It’s true that minimally invasive surgery resulted in shorter lengths of hospital stay and fewer complications in this paper but the patients in the minimally invasive group were both significantly younger and had significantly fewer co-morbidities, p for both < 0.001.

The skeptic community still awaits a scientifically valid study that proves robotic surgery is better than standard laparoscopic surgery for any disease.

Thanks to Nathan @NJHM for alerting me to the interview.

Overhyped research on prostate cancer & circumcision link

Yesterday Twitter was abuzz with tweets about a new study that showed an association between circumcision and a lower risk for prostate cancer. You wouldn’t know that it was just an association by the headlines.Here are but a few.

Circumcision Cuts Prostate Cancer Risk Scientific American
Circumcision reduces prostate cancer risk UPI
Circumcision Linked to Lower Risk for Prostate Cancer, Study Finds Yahoo News

And my favorite,

Males of the Mideast Rejoice: Circumcision Reduces Prostate Cancer Asian News International

In fact, not only is it just an association, it is a very weak association at best.

The research was a retrospective case-control study of men who self-reported their circumcision status, sexual histories and other information. There were 1754 men with and 1645 without prostate cancer in the study. The numbers of circumcised men differed by only 2.7% [1207 (68.8%) with cancer vs. 1176 (71.5%) without cancer.}

The relative risk of developing prostate cancer was not significantly different in circumcised and uncircumcised men until the authors looked at those who had been circumcised after their first episode of sexual intercourse. The numbers of men who had been circumcised after their first sexual encounter was only 68 (3.9%) of the men with prostate cancer and 41 (2.5%) of those without. Although the relative risk reduction was 15%, the confidence intervals were wide (73% to 99%) and were just barely significant.

And don’t forget, this is a relative, not an absolute, risk reduction of only 15%.

Most of the paper’s discussion involved circumstantial evidence that because infection has been linked to some cancers, infection of the prostate or penile skin may possibly play a role in the development of prostate cancer.

So does circumcision actually reduce the risk of contracting prostate cancer?

It shouldn’t surprise anyone, but I am skeptical. Do you really believe that one act of sexual intercourse before a man is circumcised would really have an impact? What if the man did not develop an infection after that episode or any subsequent episodes?

Don’t believe me? Here is a quote from Internal Medicine News, which not only had a more subdued headline, it published one of the few articles that featured the opinion of an outside expert, Dr. Stephen J. Freedland, a urologist at Duke. He said:

"This study provides modest evidence: a 15% reduction. It’s not as if we should recommend that every baby be circumcised because it can reduce prostate cancer by 15%. This is more of a research finding,"

Those males of the Mideast should probably temper their rejoicing until some more solid evidence appears. Meanwhile, they may want to consider a study from 2003 suggesting that masturbating may prevent prostate cancer.

Does Oral Contraceptive Use Increase Rates of Prostate Cancer? I Doubt It.

A recent paper linking the use of oral contraceptives by women to higher rates of prostate cancer in men has received some media attention. Two urologic oncologists from the University of Toronto in Canada published this hypothesis in an open access journal, BMJ Open. The full text is available here.

The paper’s plausibility is based on some previous work suggesting the exposure to estrogen might increase the risk of prostate cancer.

The study was done using retrospective data from various sources. Information on contraceptive use and prostate cancer was obtained for countries with all levels of economic development on all continents. The main finding was that oral contraceptive use was associated with both the incidence of and mortality from prostate cancer, while all other types of contraception showed no such association.

A fair amount of statistical manipulation was used to generate the results. When one first reads the paper, it is almost believable until one reaches the section postulating the mechanism by which this association could possibly be real. The means by which oral contraceptive use could affect prostate cancer rates is posited as increased levels of so-called endocrine disruptive compounds (in this instance, estrogens) in drinking water secondary to excretion by women.

To their credit, the authors themselves admit that the paper has some serious limitations.

Obviously, more developed countries would have higher rates of cancer screening and detection. Rates of prostate specific antigen (PSA) testing were not available. The authors felt that their method of controlling for gross domestic product obviated the need to have actual PSA screening data.

The authors further concede that there are no available data on the levels of endocrine disruptive compounds in the drinking water of a single country.

As a mere general surgeon with no ecologic or public health credibility but having seen the vast reservoirs of drinking water in my area, I find it difficult to believe that there could be significant levels of endocrine disruptive compounds in the public water supply. And what about the fact that in many highly developed countries, people drink bottled water presumably free of endocrine disruptive compounds?

An [assumed] editorial summary of the paper states “This study is an ecological study and thus has significant limitations with respect to causal inference.” Translation: There is absolutely no proof that oral contraceptive use in women causes higher rates of prostate cancer in men.

Bottom line: I’m not going to stop drinking water. Are you?