ACOG's dysmenorrhea FAQs: Evidence of propaganda?

I have been looking up information on endometriosis for a friend of mine, and came upon this from the American College of Obstetricians and Gynecologists:

So I bit and started reading. And about half way through my reading it I realized that this really reminds me of how they taught literature in the my native USSR. The teaching consisted of stock interpretations of the great authors' works through the prism of Communist Party propaganda. In this interpretation all of the writers' messages railed against the monarchy, and all exhortations were for the purpose of freeing the proletariat. No teacher ever dared to disagree, and no student was expected to question.

Why, you ask, do these ACOG FAQs on dysmenorrhea remind me of my schooling in the old country? Well, glad you asked. Check out this gem, for example:

That's it. No follow-up questions? Good!

But really let's take it from the top. So, OK, there is the pelvic exam. I can deal with that because I am used to that as the default for anything going on "down there." Then there is the ultrasounds exam. I guess I can deal with that too because there has been so much in the news about pelvic ultrasound, and that seems to be what is done to get a better look at what is down there. A laparoscopy? Wait, isn't that a surgical procedure? Yeah, they even say it's a surgery, and it's done to get a "look inside the pelvic region." Hmmm, this sounds pretty serious. How come they don't say anything here, in these FAQs, about what they are looking for, how good this surgery is at finding it, what the chances that what they find is responsible for my dysmenorrhea, what is the treatment and how successful it is at alleviating my symptoms of dysmenorrhea, and whether or not there are alternative interventions?

(Does anyone really ask the patients what their FAQs are or are they generated by the clinicians based on what they think should be important to the patient? Or even worse, based on what they think they can give a perfunctory answer to? Just from reading these Qs and As I think it's the latter.)

You get my point. This formulation of information is beyond useless. It seems paternalistic in its "there there, dear, we will take care of everything" attitude. Perhaps I am out of touch. Perhaps women, patients in general, don't want to go beyond what their doctor tells them to do. But I happen to think that it is these FAQs that are out of touch. Granted, I am a "difficult" patient, as even a pelvic exam, let alone ultrasound and surgery, meets with questions around the evidence of its effectiveness. But even if you have only completed ePatient 101, you should know enough to ask about something as serious as a laparoscopy! How can anyone be expected to just acquiesce and, sighing, say "yes, I guess I have to have surgery." This "FAQ" is completely absurd in its willful lack of useful information. And if you read the rest of the document, you will find many places where this is true as well.

I know that some of you will read this and click away saying "oh, there she goes again." But I think you need to rethink your apathy. After all, there are well over 200,000 deaths (and possibly even more than 400,000) annually in the US that happen unnecessarily just from contact with our "healthcare" system. If you can avoid the avoidable, is it not incumbent upon you to be fully informed? You may think that all these recommendations are evidence-based, and there is not a whole lot of wiggle room in how to proceed. Well you are wrong if you think so, since the evidence, even when it is available, is rarely, if ever, unequivocal. And furthermore, in medicine no benefit comes without a risk. Are you sure you want your doctor to make these decisions for you? How is it that people who are not even willing to take wardrobe advice from their mothers wade so enthusiastically into these high-risk medical adventures with their eyes and ears closed?

I wrote Between the Lines to show just how imprecise and uncertain the science of clinical medicine is. But beyond that, I wanted to provide you with tools at least to ask the right questions. So, please, go and ask. And insist that you be included in the FAQ processes. Otherwise, we are just wasting terabytes on propaganda.            

If you like Healthcare, etc., please consider a donation (button in the right margin) to support development of this content. But just to be clear, it is not tax-deductible, as we do not have a non-profit status. Thank you for your support!

Manipulating science

I picked up Devra Davis's The Secret History of the War on Cancer again, her sweeping indictment of the role politics has played in the science of epidemiology vis-a-vis health risks of smoking. The book is a great read, as it not only gives you the history of the fight, but also helps one understand the skepticism related to the methods we use to tie toxic exposures to adverse health outcomes.

One fascinating aspect of the story is the metastasis of public relations into the scientific discourse. On page 193, Davis quotes from Edward Bernays' 1928 book Propaganda:

"The conscious and intelligent manipulation of the organized habits and opinions of the masses is an important element of a Democratic society. Those who manipulate this unseen mechanism of society constitute an invisible government which is the true ruling power of our country.... We are governed, our minds are molded, our taste formed, our ideas suggested, largely by men we have never heard of. This is a logical result of the way in which our Democratic society is organized.... In almost every act of our daily lives, whether in this year of politics or business, in our social conduct or our ethical thinking, we are dominated by the relatively small number of persons... who understand the mental processes of the masses. It is they who pull the wires which control the public mind."

Note the split into the rulers and the sheep, the manipulation, the invisible governance, and again the manipulation. Sound familiar? For those of you not familiar with Bernays, he is generally considered to be the father of the public relations field. He was also the nephew of none other than Sigmund Freud, and, upon reading Freud's ruminations on the human psyche, adapted many of his ideas to manipulate consumers. In fact, it was Bernays who made it not only socially acceptable, but even desirable for women to smoke.

But I digress. What is the relevance of this quote from Bernays as used by Davis? Well, this was the strategy utilized to keep the mounting data on the dangers of tobacco from becoming credible. The popular tactic this strategy yielded was to have learned men with loud reputations refute the scientific basis of the reality of harm. Sound familiar?

I am not saying that the "learned men" of today are willfully obstructing the public from seeing the dirty underbelly of what medicine has become; I do not ascribe nefarious motives to them. However, given that we even have to ask the question "Should the public be told about the trouble with medical research?", it is an issue well worth discussing.

As you know, I am a great believer in transparency in both research and lay discourse. I believe that without a robust debate about topics that are far from clear, regardless of what the "learned men" will have us believe, we do harm to the society in several ways. First, lies damage relationships. Second, obfuscation creates distrust and sets up an adversarial atmosphere, which eventually leads to subversion of intentions, no matter how noble. Just look at the vaccine "debate" and how polarizing and destructive it is to both individual and public health. Third, it is manipulative and disrespectful, presuming lack of intellectual sophistication in our population. And while I am well aware that our literacy and numeracy are at an all time low, catering to the lowest common denominator is nothing but accepting and propagating the status quo. A better solution, though more time-consuming, is to start to fill these education gaps to improve our collective ability to engage in an edifying discussion.

To assert, as has been done here, that questioning any aspect of either the vaccine usefulness or the science of evolution for that matter equates to supporting the "anti-vaxers" or creationism, betrays a deep misunderstanding of how science is advanced. Indeed, it is by questioning certain aspects of science that do not seem to make sense that scientists both gain a better understanding of these ideas and at the same time demonstrate to the public how different our ways are from the entrenched dogma of organized religions.

I for one am proud of the process of science, and for this reason am working to bring what is under the hood out in the open. If we hide the messy uncertainties of our craft, we are doing a disservice to ourselves, our patients and the public at large. Worse yet, we are engaging in the manipulation, thus relegating scientific method to the wastebasket of PR and politics.