White Coat Underground

I was a bit torn when trying to figure out how to approach this piece.  A reader emailed me about an article in the Huffington Post, and there is so much wrong with it that I felt overwhelmed.  My solution is to focus on a few of the problems that can help illuminate broader points.

There is a small but vocal movement of people who refuse to believe that skin cancer caused by sunlight is a significant health risk.  These people tend to also believe that the risk is being purposely hyped by others, and that our current approach to skin cancer prevention is causing an epidemic of vitamin D deficiency. Leaving aside the seemingly insane denialism regarding sunlight and cancer, there are two broad problems with this article.  The first is pretty bad.

With the summer months upon us I wanted to find out firsthand what exactly the mantra is that dermatologists are telling patients. So I went undercover to several San Francisco dermatologists in order to see if there is legitimate concern about the sun-scare media hype. Are these doctors being sensible or going overboard when it comes to advice on sunscreen use and skin cancer prevention? Is the sky falling with dangerous UV rays or are we being induced into a media panic?
 

He goes on to give links to recorded conversations, and prints out partial transcripts.  He does not specify whether or not he received permission to record these conversations, as required by California law.  Whether or not the law requires it, the writer should have disclosed to his readers whether or not he had received permission.  This information is important in interpreting the conversations he reports to us.  

The next problem is broader, and deals with physicians’ willingness to lie on behalf of patients.  The author’s presumably-clandestine recordings of his deceptive visits to dermatologists (catching my breath—this is striking and requires a digression.  The act of deceiving these doctors is not only unethical, but can influence the outcome of the visit.  Doctors make the assumption that most patients are interacting with them out of good faith, and are not intentionally deceiving them.)

In the first conversation the author has with a doctor, the interviewer makes it clear that he wants a mole removed, and the doctor essentially leads him to say “the right thing” so that insurance will cover the procedure.  One thing the author seems to miss is that the dermatologist is going to be paid whether or not insurance covers the procedure.  If the insurance company says “no”, the patient will be billed.  The doctor is lying for the patient, not for herself.  

Data have shown that physicians are willing to lie on behalf of patients. There are a number of reasons that this poses ethical problems.  It could be argued that the doctor is lying to help get the patient something that they need, and that lying is a peccadillo compared to the benefit.  This can backfire in a number of ways, not least of which is that both the doctor and the patient can probably be prosecuted for fraud, something that is unlikely to be of benefit to either one.  

But there is a fine line between a lie and a truth, one that anyone familiar with the intimacies of the exam room will often experience.  As a doctor, your overall impression may be that the patient is at high risk for coronary artery disease, but perhaps the patient doesn’t quite meet the insurance company’s criteria.  You can then lay out the cost of the test and the risks and benefits for the patient, but I wouldn’t be surprised if some doctors took the short cut of asking, “are you sure you’ve never had any chest pain or difficulty breathing?”  

He begins his second dermatology visit by telling the doctor that he has a family history of melanoma, and finds fault in the doctor’s description of the statistics of the disease.  The problem of properly rendering statistics is a common one, and he links to an excellent piece by Ivan Oransky explaining the difference between relative risk and absolute risk.  Unfortunately, he uses this to spin a tale of some sort of dermatology conspiracy to inflate cancer numbers.  Skin cancers (including melanomas and non-melanoma skin cancers) are very, very common, and though many are not fatal, their diagnosis and treatment can be expensive and disfiguring.

His visit continues and the doctor tells him that insurance won’t cover his mole removal because it’s not necessary, and refuses to lie in the medical record. The doc then gives some sound medical advice about how to prevent skin cancers.

I then ask what measures I should take to prevent skin cancer. I’m told to apply sunscreen 24/7, wear a hat and sunglasses, as well as avoid the sun as much as possible. (The only thing she doesn’t mention is to live underground with the mole people.)

“Mole people”?  He asked the doc how to prevent skin cancer, the doc gave the correct answer.  It’s up to the patient to decide if the application of sunscreen is too onerous for the potential benefit.

This article shows a misunderstanding of journalistic ethics, medical ethics, and medical science.  It’s a disaster.  And it’s no surprise that it’s in the Huffington Post.

Comments

  1. #1 Toast
    July 14, 2010

    Ah, but … don’t forget (will you ever?) that abortion causes breast cancer!

  2. #2 angela
    July 14, 2010

    That article certainly was overwhelming with all its problems! My head hurt just reading it… Just wanted to say your response was excellently directed with some great points. Thanks!!

  3. #3 D. C. Sessions
    July 14, 2010

    Nyah, sun exposure has nothing at all to do with skin cancer. Anyone knows that.

    For instance, primary skin cancers (esp. melanoma) are equally common all over the body, not just in areas exposed to the sun. That’s why there’s equal rates of skin cancer on left and right arms, too: arm-out-the-window sun exposure has no effect.

    That’s also why skin cancer rates are uniform all over the world: it makes no difference whether you live in a tropical beach resort or in Finland, Australia or Scotland, your chances of skin cancer are exactly the same.

    </sarcasm>

    DCS, looking at all of the scars on my left arm from assorted basal cell carcinomas, actinic keratoses, etc. that I’ve had for the last 30 years. Funny how the right arm never developed anything of the sort, and funny how all of the rest I’ve accumulated are on areas which were exposed to the sun instead of my butt or other covered areas.

  4. #4 Jon H
    July 14, 2010

    I find it hard to believe that the author waited until summer to schedule appointments with dermatologists, and was actually able to get multiple appointments before autumn.

  5. #5 _Arthur
    July 14, 2010

    Yes, I’m too lazy to find the precise reference. but the vitamin D prophet, Dr. Cannell, once calculated (or estimated) that sunscreen was a DANGEROUS PRACTICE because high levels of vitamin D (the higher the better) “protects you from cancer”, and it protects you MORE than your die from skin cancer, or something like that.

    So, health guru Gary Null must be really cancer-proof by now, after takin 2 million UI of vitamin D per day for a month, and lived to tell the tale.

  6. #6 Lycanthrope
    July 15, 2010

    In terms of medical blogs, I read both this one and Respectful Insolence. I find them both very interesting, informative and often thought-provoking. But the one negative is that, like today, I sometimes read about flavours of denialism I never knew existed. Until I started reading these blogs, I never even knew about the anti-vaccination movement. (I live in Canada, where as far as I can tell, it’s not nearly as big a problem.)

  7. #7 Mary Mills Barrow
    July 15, 2010

    We, too, saw this piece and were appalled by the implication that dermatologists are unethical and that skin cancer provides some sort of profit machine for them. Interesting that the author failed to point out the hundreds of free skin cancer screenings derms provide every year in so many communities around the country. Nor did he bother to mention the unstinting efforts at public education derms commit to both through professional organizations and individually. Thank you for a thoughtful and thorough response to this irresponsible “journalism.”

  8. #8 Jud
    July 15, 2010

    D.C. Sessions writes:

    Funny how the right arm never developed anything of the sort, and funny how all of the rest I’ve accumulated are on areas which were exposed to the sun instead of my butt or other covered areas.

    Why does the phrase “Skin cancer, my ass!” run through my mind upon reading this? (Or maybe it should be “…not my ass!”?)

    I have a family history of colon cancer (both grandmothers, multiple aunts and uncles) and wanted a colonoscopy at age 48. The doctor said insurance wouldn’t pay for someone under 50 to have it done, even with my family history, unless I’d experienced symptoms that might call for the test. Then he said, “We’re going to say you’ve had some problems with constipation,” and looked at me, pen poised. I hadn’t, so of course I answered “Oh, yes.” The insurance paid, I had it done, and happily got the all clear.

  9. #9 ambivalent academic
    July 15, 2010

    Heh. Mole people. One might argue that the “mole people” (as in, people who have moles which may or may not require removal) are in fact the ones who live *above* ground. Mole people (as in those bearing resemblance to small blind mammals) who live below ground presumably have fewer (at-risk) moles. Love the inadvertent double entendre.

  10. #10 Susan
    July 15, 2010

    I think your hypotheses are off on all counts:
    1. Investigative journalism works because it’s undercover
    2. You’re shocked than any MD would even conceive of the desire for a profit margin or abuse of the insurance system (well documented). Let’s get real please.
    3. You’re even more shocked that corporate interests, relationships and marketing efforts could influence MDs to get patients to wear sunscreen 24/7/365. Really? MDs were peddling cigarettes back in the day. The CDC already stated that they have not reviewed sunscreen chemicals for 10 years, even though there are KNOWN carcinogens in many OTC products. Why not advise your readers to check out the Environmental Working Group’s paper:
    http://www.ewg.org/2010sunscreen/9-surprising-facts-about-sunscreen/

    Time for folks to use common sense: get 15 min of UV light, get your vitamin D and then put on a hat/long sleeves or seek shade. What other product, besides food and water, do you ask 100% of your patients to ingest or apply everyday? Better living through chemicals is really making us sicker.

    4. While everyone is berating the sun, that giant orb that keeps all life living on the planet, I think derms and cosmetics derms in particular that care more about wrinkle prevention (read Botox $$) than melanoma, believe that our health is only skin deep. And that’s the real mistake here.

  11. #11 D. C. Sessions
    July 15, 2010

    While everyone is berating the sun, that giant orb that keeps all life living on the planet, I think derms and cosmetics derms in particular that care more about wrinkle prevention (read Botox $$) than melanoma, believe that our health is only skin deep. And that’s the real mistake here.

    Unhhh — right. You’ve obviously never met me, or the vanity joke would have backfired so badly as to land you in a trauma center.

    However, I’ve had enough experience (as above) with actinic skin lesions that I’ve learned to be one of those zinc oxide addicts. Funny thing, though: my general health is dandy, my bone density is better than most people 20 years younger, and my MD doesn’t get a dime from either my purchases of UV protection or the chronic illnesses you insist are resulting from using sunscreen.

    Meanwhile, my uncle who spent his youth sunning on the beaches of southern California is still dead and his grandchildren never got to meet him because he died of melanoma before he was 50.

  12. #12 Pastor P
    July 15, 2010

    I know it seems ridiculous to highly-educated people, but common people really take television as truth. Living on the ground floor, so to speak, I have personally seen people watch commercials about skin cancer and decide not to go to the pool anymore. Considering that less time in the sun inevitably seems to lead to spending time working, watching TV, or online (which nowadays, inevitably generates income for other people)…

    Well, maybe it’s not toooo crazy to imagine that at least a few high-powered people/corporations intentionally hype up skin cancer. Perhaps the people who see the same effects on regular people as I do feel that they have to be extreme in order to counteract that?

  13. #13 Isabel
    July 16, 2010

    “Would this explain why the United States has just 4.5 percent of the world’s population but has 52 percent of the world’s melanomas when you compare the American Cancer Society’s numbers (68,720) with those from the World Health Organization (132,000 worldwide)? ”

    Yeah what’s with that?

    Sunscreen on your skin 24/7 is indeed an extreme recommendation. I rarely use it, only when I am on vacation somewhere closer to the equator and going out on a boat or something. I try to cover up, but I agree, we absorb substances through our skin and no one even seems to know what’s in sunscreen or if it really works!

    Finally, the concerns about the effects on the ecosystem are reasonable also. Why just bash the article? Can you address these serious concerns?

  14. #14 herb
    July 16, 2010

    The latest issue of the Lancet has a commentary on sun and vitamin d.

    “Cancer Research UK recognises the need to balance skin cancer prevention with generation of adequate vitamin D, but specified that “the skin efficiently produces vitamin D at levels of sun exposure below those that cause sunburn…when it comes to sun exposure, little and often is best”. Australia’s SunSmart guidelines underwent a revision to reflect this balance in 2006—07.” It’s hard to argue against these common sense recommendations, though the US dermatology establishment continues to do so.

  15. #15 joseph
    July 17, 2010

    @isabel

    who is most likely to get melanoma? fair skinned caucasians, with the most significant chance for those living in sunnier places than northern europe.

    hence, america and australia.

    there are a lot of asians, hispanics, and africans in the world. but they are much less likely to get melanoma.

    common sense, not conspiracy.

  16. #16 Mills
    July 17, 2010

    “These people tend to also believe … that our current approach to skin cancer prevention is causing an epidemic of vitamin D deficiency”

    I don’t find rebutting HuffPo’s generalised hyperbole with generalised hyperbole to be very effective!

    How about some facts:
    1. Most people meet their vitamin D needs through exposure to sunlight (NIH) – at least 90% (unless you have a very high fish diet).
    2. SPF 8+ blocks vitamin D-producing UV rays (NIH)
    3. Vitamin D deficiency levels in the US are increasing (NHANES II vs NHANES III).
    4. Increased sun exposure does not directly increase the risk of melanoma (people who work outdoors have less melanoma). Irregular sun exposure and sun burn are the main factors.

    Lifestyle may turn out to be the main cause of the increase of vitamin D deficiency, but the over prescription of (un-trialled) sunscreen cannot help (and there is certainly a subset of educated mums who won’t let their little ones outside plastering them with SPF 50). I think the onus is on the sunscreen industry (and the dermatologists) to provide evidence to the contrary, and “these people”, along with the rest of us, are entitled to point the finger at the current skin cancer prevention programs.

  17. #17 PalMD
    July 17, 2010

    That is well-reasoned, but lacking.

    Yes, a history of blistering burns are correlated strongly with melanoma. Yes, sunscreen prevents blistering burns.

    Yes, long term lower intensity sun exposure is strongly correlated with non-melanoma skin cancers. Yes, sunscreen can mitigate the effects of long-term sun exposure.

    Are there excellent data looking at sunscreen use and skin cancer rates? Not that I’m aware of, so we’re taking a short leap from “bad condition caused by X, X mitigated by sun avoidance, therefore sun avoidance (with sunscreen being part of that) very likely prevents bad condition”.

    Living we up here in this bit of the northern hemisphere, it is not clear that the risk of intense or frequent or long-term sun exposure is worth the “natural” vitamin D production. Lots of things are “natural”; like cancer.

    We regularly test for vitamin d levels in this part of the world because a large percentage of people, sunscreen or not, are not going to get a lot of UV exposure most of the year. Oral supplementation, when necessary, is more that adequate, without the pesky carcinogenesis.

    But of course, supplements are only cool when they are prescribed by naturopaths for conditions that they don’t help. When a real doctor prescribes one, they are just in the thrall of big Pharma.

  18. #18 Isabel
    July 18, 2010

    “We regularly test for vitamin d levels in this part of the world because a large percentage of people, sunscreen or not, are not going to get a lot of UV exposure most of the year.”

    So why do we have 50% of the melanomas? Are they concentrated in the Southern States? It would be nice if the recommendations were regionally specific at least, especially since we don’t know the risks of using sunscreen (on us OR the environment).

    I always felt slowing tanning was protective, but the prevailing wisdom from the medical establishment is that it is evidence of harm. Is it more harmful than using sunscreen? Nobody knows, but they give this absolute advice anyway.

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