21st Century Snake Oil
A pink advertising insert appeared in my local newspaper recently proclaiming that “We can help you Stay Stroke Free for only $149!” The ad by Life Line Screening urges readers to undergo ultrasound examination of their carotid arteries because “80% of stroke victims have no apparent warning signs or symptoms.” The ad further asserts that “when detected early, 4 out of 5 strokes can be prevented.”
Based on this ad, readers would seem to be well advised to call immediately for an appointment. But if they did so, they would be unnecessarily putting their lives at risk.
What the ad doesn’t say is that stokes caused by a blockage of the carotid artery comprise a relatively small proportion of all strokes and that even if severe blockage of the carotid artery is found, surgery to clear that blockage is more likely to cause a stroke or kill you than not doing surgery. That was the conclusion reached by the American Academic of Family Physicians (AAFP) which, as part of the Choosing Wisely campaign, is urging doctors not to screen for carotid artery blockage. The AAFP wrote, “There is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits. Screening could lead to non-indicated surgeries that result in serious harms, including death, stroke and myocardial infarction.” Furthermore, the screening test is far from perfect, sometimes indicating that a severe blockage is present when it really isn’t.
The United States Preventive Services Task Force (USPSTF) also recommends against screening in adults who show no other symptoms of carotid artery stenosis. And even if a patient has another symptom or risk factor for stroke and other cardiovascular diseases, the recommended response is to practice good health habits like regular exercise, control high blood pressure or diabetes if they are present, and eat healthy—and, if you are older, take a daily aspirin. So knowing if there was a blockage in the carotid artery would not lead to doing anything different.
So what motivates Life Line Screening to scare readers into getting the test? I think money has a lot to do with it. Their ad boasts that nearly 8 million people have already been screened. At $149 per person, that’s over a billion dollars.
Another screening company, Health Fairs, has been doing a similar form of cardiac screening, which evidence shows is equally unnecessary. This led Public Citizen to write a letter to 20 hospitals and other medical institutions urging them to sever ties with Health Fairs. Public Citizen writes, “the company’s heavily promoted, community-wide cardiovascular health screening programs are unethical and are much more likely to do harm than good.”
In response to Public Citizen’s letters, the American College of Cardiology blogged that “[o]ther than assessing blood pressure and serum cholesterol, being attentive to diabetes and promoting a healthy weight with regular exercise, we do not recommend broad and untargeted screening.” And an op ed in JAMA supported Public Citizen’s call for hospitals to sever ties to these screening companies if they cannot justify the relationship transparently, and to fully disclose to patients the risks and benefits of the screenings offered.
This fear mongering isn’t confined to shady operations conducted from buses or rented VFW halls. Television ads from large commercial clinical laboratories urge viewers to get tested for celiac disease if they have any of a long list of common symptoms that just about everyone has experienced at one time or another like bloating, gas, indigestion, constipation, diarrhea, nausea, vomiting, or decreased appetite.
Pharmaceutical companies are in the “selling sickness” business in a big way as well. TV ads alert men to the symptoms of “Low T” (low testosterone) including fatigue or decreased energy. A recent patient came to me insisting on a prescription for the transdermal testosterone patch based on vague symptoms, while arguing that he didn’t need any blood test to confirm the diagnosis. In a January article, AARP warned that new research has linked such testosterone hormone therapy with a significantly higher risk of heart attack, leading FDA to review the safety of this treatment. A physician AARP interviewed advises men to see a physician that is qualified to make a proper diagnosis, but to avoid medical centers that “seem too promotional”.
America has a long history of hucksterism. “Snake-oil salesmen” sold their patent medicines to gullible consumers throughout the 19th century. The progressive movement in the early 20th century curtailed some of the most outlandish practices through pure food and drug laws and tighter regulation of untruthful advertising. But it seems as if we’re now turning back the clock to the days of the Wild West with increasing clamor for less government regulation and an unfettered free market.
Free markets work well when consumers can be armed with the all the information they need to make rational choices. But in health care, reliable information is complex and hard to come by, and consumers are also patients, who feel personally vulnerable. Patients should have a voice in treatment choices, but they can also be misled into buying services and products they can’t fully assess, and don’t really need.
What we need is more stringent government regulation of advertising of health products and services, not less. Ads should be prohibited not only when they are blatantly false, but also when they are so unbalanced, or incomplete as to become misleading. For instance, if an ad contradicts a recommendation of the USPSTF, then the ad should be required to include the task force’s recommendation verbatim.
We also need to do a much better job letting the public know about trustworthy sources of health information, such as Choosing Wisely and Consumer Reports Best Buy Drugs. In this day of iPads and instant information, no one should get snookered into buying 21st century snake oil.
Stephen R. Smith, M.D., M.P.H., Community Catalyst physician consult