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.