Q&A with Gary Schwitzer: People need fewer hot fudge sundaes in their health report
Gary Schwitzer is the professor that health reporters fear. With the creation of HealthNewsReview, he has brought back nightmares of having your work marked up in red and posted on a corkboard for everyone to see. A former lead medical reporter for CNN (a job later filled by Sanjay Gupta), he now teaches at the University of Minnesota, writes a blog and regularly opines on the precarious state of health reporting.
I reached him via email. Here is a recap of our conversation, which has been edited for space and clarity.
Q: Tell me about a story you worked on early in your reporting career that helped make it apparent to you that medical reporting required a deeper level of analysis than a typical crime or even local government story.
A: I clearly remember 1984-1985 as a turning point in my career and, I believe, in medical news coverage. We had the artificial heart team firing up again in Louisville after moving from Utah. The media onslaught was unbelievable. We had the baboon heart transplant in Baby Fae at Loma Linda. We had Steven Rosenberg at the National Cancer Institute working with pet media to promote interleukin for cancer. It was, to me, the year that journalism went nuts over medical news. I was in the midst of it at CNN then and had a difficult time getting editorial decision makers to let me get beyond the headlines to some of the context that I felt was important. Claims were being accepted without challenge. Context and background and tough questions took a backseat. I was 33.
By the time 1985 was over I had produced and reported a half hour special called "Hope or Hype." My attitude and my reporting changed from that year moving forward. I didn't last long - resigning from CNN just five years later because I couldn't stand the flawed editorial decision-making that I saw being employed every day. Plus, our medical news was sponsored by a drug company - a situation I could not tolerate but a situation that didn't seem to bother anyone else at the network. I was waking up to big money and conflicts of interest in health care and in health care journalism.
Q: You have derided "news you can use" stories about new treatments, diets and medications as distractions from more serious examinations of health policy and health disparities. But how can you fault news organizations, which are struggling to keep their audiences, for giving people what they demand?
A: Your question is based on a false premise in my eyes. We don't know what people want, need or demand. First, it was not just I, but dozens of health care journalists I've interviewed, who hammered away at their hatred of the "news you can use" trend.
Second, I don't think there's been a good, fair test of what people want or demand from health news coverage. What they're getting now is the health/medical news version of OJ in the white Bronco. Of course they'll watch that. I watch it. But it's a steady diet of hot fudge sundaes without any broccoli. (OK, my hot fudge sundae and white Bronco analogies are my two best, and I've just given you both of them.)
The people I know, the people I talk with -- and I'm not talking about academics but REAL people with real needs -- demand help navigating a non-system of health care in the US. They want to know what they're paying for in health care and nobody can tell them. They want to look to journalism to be a navigator, a traffic cop, a filter. They're thirsty for just a sip of meaningful, balanced information on quality, effectiveness, evidence, costs. Instead, they often get drenched by a fire hose gushing story after story about breakthroughs and new stuff.
Look at all the stories in the past three weeks leading up to the ASCO conference - dozens of stories based on abstracts of talks that hadn't even been given yet. That's CRAZY! This stuff hasn't been vetted! I believe we need fewer news stories about new stuff and more about uncertainties, inexplicable variations in health care in the US, disparities, access issues, questions of comparative effectiveness, individual decision-making, conflicts of interest in health care and science, etc.
Q: Along those same lines, you have noted that in your recent survey of health journalists, nearly a third of the journalists said that their news organizations allow advertisers or sponsors to influence health care news at least some of the time. Why did this surprise you, given how much economic pressure there is on journalistic organizations right now?
A: Despite how hard-assed some people think I am about health care journalism, I still want to believe that a firewall exists in newsrooms. I thought that survey admission by 31% of respondents that this happens at least sometimes in their newsrooms was a shocking revelation.
Q: Let's talk a little bit about Health News Review. You set up 10 criteria for ranking stories, and you give each story zero to five stars. Most stories end up with three stars or fewer. Have you considered that your standards might be too high for mainstream journalists who are not immersed in the nuances of health care the way you are?
A: Our criteria aren't about "immersion in nuances of health care." We've simply been the first in this country to put a stake in the ground and say, "We think these are the criteria that need to be addressed in health care stories. If you disagree with us, let us know how. Let us know what criteria you use." There has NEVER been a meaningful, substantive comeback to that statement.
I've challenged some reporters, "If you disagree with our criteria and don't think they are important, tell us which ones are not important in every story? Costs? Quantifying benefits or harms? Having independent sources? Checking on conflicts of interest in the sources? Which are not vital? And your answer will be on the record." Again, there's never been a meaningful, substantive retort.
If our simple little criteria set the bar too high, then I think we may as well fold the tents and turn it over to the advertisers and marketers. I feel confident that anyone who spends any time with our criteria - and how we apply them to the review of stories - now 800 times in the past three years - would agree with me. And most journalists have embraced what we're doing. They seem to welcome the independent, expert, external scrutiny that they know they're often not getting within their own newsrooms.
Q: Most of the reviewers are doctors or academics. Why not include more journalists in the process?
A: We now have four journalists involved in story reviews - me, Craig Stoltz (former Washington Post health section editor), Andrew Holtz (former CNN journalist and former president of the Association of Health Care Journalists), and Colin Nelson (former editor of Bone & Joint and Sports Medicine Digest and associate editor of The Back Letter). I would predict that we'll have a couple more journalists involved within the year.
It's funny: everyone wants more from us. Everyone has a list of news organizations we don't review that they think we should. Some people want us to add more journalist-reviewers, more nurse-reviewers and more integrative health care-reviewers. I just want to say, "Folks: Chill. None of us work on this full-time. I've run this site while maintaining a full academic commitment for the past three years. There isn't anyone else like us." Nonetheless, I always welcome the suggestions and hope to address some of them during the next year as I take a leave of absence from the university to address some of these tasks that have been piling up.
Q: Have you noticed a change in any specific areas of health reporting as a result of your reviews?
A: From year one to year three of our operation, we measured small, slow, but steady improvement in journalists addressing seven of our 10 criteria - including the three worst: costs, quantifying benefits and harms. This was the average of all stories reviewed - and a look at how they fared on each of the 10 criteria - between year one and year three. For there to be such improvement at these troubled times in newsrooms makes it very significant to me. Network TV news continues to drag down the curve however. They consistently rate poorly - even on looooong six minute segments on their morning programs - and they're not getting any better.
Q: What sort of blowback have you had from journalists or news organizations?
A: Stunningly, it's been overwhelmingly favorable. I traveled 30,000 miles last year just giving talks and workshops about the project. I spoke with journalists in Chicago, Philadelphia, San Francisco, New York, Boston, Seattle. Many say they love the mouse pads we give out that list the 10 criteria. They say it helps them to remember to address these things which otherwise may easily be left out. When we launched in April 2006 I expected a great deal of defensive reaction. It hasn't happened. That says a lot about the dedication to quality improvement that most health care journalists make. The single biggest piece of feedback is "Why aren't you reviewing us?" It could be that these journalists think they're doing a good job and want a public pat on the back. Or they may be clueless about how well they're doing and they thirst for our independent, external, expert review. Either way, I think it's a fascinating piece of feedback that I hear over and over wherever I go.
Q: If you had to pick the "Top 5 health topics that are poorly reported," what would they be?
A: 1. The overselling - to the point sometimes of almost crusading advocacy - of screening tests.
2. The inexplicable variations that exist across the US in the way medicine is practiced. As often as this story has begun to be reported, it can't be reported enough. Jack Wennberg's work is crucial for any journalist, any health care consumer, or any politician to understand.
3. Costs. We spend a greater percentage of the GDP on health care than any other country, still come in 30th-40th in the world in infant mortality, still leave 16% of our neighbors uninsured, and we still don't cover the cost of health care adequately.
4. All health care reform is local. What is happening in your town?
5. Conflicts of interest in medical science and in health care. They exist around every corner. And we are not having a public discussion about where we draw the line. I served on a university medical school conflict of interest committee this past year. It was an eye-opening experience.
Q: One measurement that you use is costs, whether the stories mention the costs of the treatments, drugs, etc. Is that too much to ask for stories that are already tightly packed with a lot of technical information that has to be explained to a lay reader about the illness being treated, other treatments, the advance in this treatment. I agree that costs are important, but can they really be included every time?
A: We're a long way from talking about including costs in every story. Right now costs are not covered 72% of the time in stories about new treatments, tests, products and procedures. It's an amazing statistic: 72% of 800 stories by 60 leading news organizations over three years' time - in the eyes of three independent reviewers analyzing each story each day.
As a journalist, I always look in the mirror first. I think journalism has to take a significant portion of the blame for the 16% of the GDP we now devote to health care because stories often drive up unrealistic expectations and create undue demand for costly, unproven technologies that may carry more harm than benefit. People don't know what they're paying for. They don't know what they're signing up for at enrollment time. They don't know why they get all of those "This Is Not A Bill" statements after they seek care. They don't know what the numbers mean and journalists haven't helped much. It's hard to argue with our data.
Q: When was the last time you read a health-related story and felt like kissing the reporter for getting everything right?
A: It happens all the time:
When John Carey wrote the Lipitor cover story for BusinessWeek in January 2008 and nailed the number needed to treat or NNT issue.
When Shannon Brownlee wrote about questions surrounding cancer screening tests in Readers' Digest this past spring.
When the Milwaukee Journal-Sentinel - a little paper that faces all of the same tough times (or more) as any other paper - accepted an award from our project last February for being the medium-sized paper with the most high scores in our first three years.
When the Minneapolis Star Tribune last winter reported on conflicts of interest with the guy who headed the conflicts of interest task force at the University of Minnesota medical school!
When Jeremy Olson of the St. Paul Pioneer Press reported on "The Death of Subject 13," which was about conflicts of interest in psychiatric drug trials at Minnesota in 2008.
When one of my undergraduate students - in her last piece for the Minnesota Daily student newspaper - asked tough questions about whether the Twin Cities really needs five different children's hospitals - and why are two are being built/expanded right now. An undergrad.
There's hope. I see it every day.