The Problem of Statistics vs Individuals – Conveying the Impact of Detailed Information in Simple Messages
One of science’s great challenges is to meet the multiple demands of the accuracy of statistics, and the visceral grip of an individual story. Medicine is perhaps the field most impacted by this challenge. Healthcare studies have the additional challenge of avoiding the implication that a simple message contains conclusions and advice that are inappropriately influenced by the money that funded the work.
About a week after the American Heart Association and American college of Cardiology issued new guidelines for cholesterol levels, Amy and I were eating dinner with an experienced cardiologist, Richard Friedman. Amy asked him about the new numbers – leading to one of the most compelling examples of championing science we have encountered. With an annual worldwide industrial research budget of more than $189 billion, medicine is the big science of our day, and that sheer volume of information makes it one of the most challenging for a champion. Dick Friedman shows us one way to succeed.
No field of science or technology bombards us with more information than medicine. It seems that every day we hear of a new study extolling the virtues of a behavior that yesterday’s study assured us was likely to cause cancer. Ads proclaim the arrival of a new wonder drug, thinly veiling the fact that the multinational corporation has a clear interest in selling the drug even if it has a minimal benefit. Worse yet, the drug may be treating a condition that we could have avoided by adopting a healthier lifestyle. In this environment it is all too easy to assume that the massive amounts of money spent on health care make the champions of health into champion salesmen. And the presence of so much salesmanship in the healthcare industry makes it difficult for the honest champion to impart the positive and life-saving messages we need to hear.
Statistics are the first currency of healthcare advice. Studies of thousands of people are required in modern medicine. But as we know from the Hollywood storytelling, one death is a compelling story, but multiple deaths simply do not have the individual impact. (For an excellent discussion see Olson et al., Connection: Hollywood Storytelling Meets Critical Thinking). It is easy to remember how a new treatment saved the life of our friend, and because of that, these individual, anecdotal, stories become the important second currency. Our science training, however, tells us that the first currency, the statistics of thousands, with the difficult extra variables carefully controlled and removed, is a more valuable way to talk about health. But no matter its value, even to scientists it is difficult to keep our focus without the individual story of tragedy or triumph.
How can a healthcare champion meet these multiple demands of the veracity of statistics, the grip of the individual story, and perhaps most importantly, avoid the implication that their advice is influenced by the pervasive money of big medicine?
Most stories of success in healthcare have a physician as the hero. While we are not too sure how to think about drug manufacturers like AstraZeneca or Pfizer, most Americans trust their doctor. Since the days of Marcus Welby, Americans cherish the concept of the doctor who labors night and day on our behalf, and I believe that is the self-image shared by most physicians of today. Medicine is a labor of love and individual successes. Every day Dick Friedman treats patients with heart disease as a cardiologist at Scripps Mercy Hospital in San Diego. His avowed passion is worthy of the best champions of science – he would love to put himself out of business. He sees education and providing clear choices for managing heart disease as the most important part of that job, and he has developed a plain and informative manner for discussing the complex issue of heart disease, diet, and fitness.
A trim and clearly fit man in his early 60s, Dick never takes off his pedometer (except for the five of them that he has destroyed on vacation when he inadvertently wore them in the water – most recently while snorkeling!). He climbs 12 flights of stairs at least three round trips a day in his hospital. Amy and I wondered how such a paragon of good heart health could discuss the question of weight with his obese patients. Careful not to be condescending or insulting, again he had a straightforward and individualized approach. Rather than citing statistics, he asks his patients about their goal. A typical 5’4″ man will live the longest at a weight of 135 lbs (there are statistics behind Dick’s messages) – and if the patient weighs 350 lbs, they are asking their heart to do the work of three. If they want to live a long life then clearly their heart will be happier at 135 lbs – but if long life is not the goal, proceed at 350. By converting the statistics (millions of people’s life spans) to a small multiplier (three) on your heart’s workload, he makes the message personal. By phrasing the message in terms of the extra work for your heart, he also sends a message of the immediate benefits of losing weight – certainly your heart is happier at two, or even two and a half, times the work, when today it must do the work of three.
But Dr. Friedman’s best champion story is around the success of statins. There is no more divisive discussion in the popular literature about the benefits of cholesterol control than any other topic I am aware of today. Is cholesterol the cause of heart disease? In my youth my health-conscious parents restricted us to one egg a week, while we slathered our sandwiches with transfat laden peanut butter. Today we think very differently. The idea that direct consumption of cholesterol is the source of high levels in your bloodstream is widely denied. The debate continues over the cholesterol-reducing benefits of exercise, drugs, and other dietary factors like fiber. Taking the high-profile aspect of the argument are a bevy of well marketed statins, drugs that are well known to reduce the levels of low-density lipoproteins (bad cholesterol) and increase high density lipoproteins (good cholesterol). Understanding the numbers – physician speak for the measured levels of the various lipoproteins – is a daunting task for even a scientist. The Mayo Clinic web site lists sixteen different values and types of lipoproteins and their health indications! Faced with a marketing blitz on TV, and magazines read by anyone over the age of 30 that simplify this complex phenomenon to “take this drug”, it is easy to wonder whether these are wonder drugs, or if the benefit is mostly in the wonderful salesmanship of all those elegantly dressed drug representatives we see chatting with our trusted doctors. Again the statistics tell a compelling story – low cholesterol is associated with low heart disease. But are the statins a cause of good health? Are the statistics the answer?
Dick takes a compelling approach. He does not cite the numbers, he cites his personal experience. He tells the story of the myocardial infarction, (heart attack in common parlance), from the perspective of the emergency room. When his pager goes off in the middle of the night, it is often to respond to this cholesterol-related event. The buildup of cholesterol plaques reduces the overall blood flow to the heart by gradually restricting the size of the arteries that bring fuel to the hardest-working muscle in your body. But Dr. Friedman does not regard the gradual blockage as the urgent killer. Rather, the myocardial infarction is a rapid event that requires you to perform a cardiac catheterization procedure within 90 minutes to minimize damage to the heart. Medically this starts with a small tear or disruption in the cholesterol deposits clogging the artery. Responding to the damage, clotting begins at the site of the tear. The combination of clotting response, and rupturing of the cholesterol plaques, can quickly block the artery. Blood flow to the blocked portion of the heart stops, and damage to the heart muscle begins. The faster your blood vessel can be opened by the cardiologist the better. Time is muscle. The ultimate result is to have no damage at all. And time is mostly used in discovery – getting to the hospital, getting the patient’s heart restarted if necessary with the ever-so-heroic emergency room procedures, getting the results back that say the stoppage was caused by the blockage and not a drug overdose or electric shock or any of the dozens of causes that the emergency room must consider. The myocardial infarction, and ultimately the short time to begin the catheterization procedure, is the reason Dr. Friedman is so attentive to his pager. He lives to save lives.
But it is not the urgent response of the trained medical team that becomes the focus of Dick’s story at this point. Having described the events in the artery, and in the hospital, and in the minds of the medical staff trying to diagnose the event, he stops the story. He proclaims that only once in his experience has a myocardial infarction started that 90-minute clock of life, in a patient taking statins to reduce cholesterol levels.
The message is clear. Dr. Friedman thinks you should take statins for high cholesterol, marketing blitz or not, garlic and oat-bran diet or not. And I bet that every person who hears this story believes him – and takes their medicine, or goes and asks their doctor to check their cholesterol level. It is not the statistics, which are so clearly in favor of the medication. It is the personal story from the man who is dedicated to putting himself out of business by conveying clear medical advice in ways that people can understand. He has iconified the entire medial experience of our fascination with M*A*S*H and ER and Grey’s Anatomy, and conveyed the benefit of taking action, of taking the medication, in terms of his own experience. He tells patients that taking statins is like wearing your seatbelt and your shoulder harness while driving a car equipped with airbags. Statins dramatically lower your risk. He has iconified the statistics with his own decades of medical practice. With the perfect grey hair of experience, you know that he has seen the scenario play out hundreds of times. The story brings all of that experience of medical procedure from popular culture together with all of the training and practice of board-certified cardiologists– an enormous body of knowledge. And Dr. Friedman uses those icons to tell the story, and compel the action, in about five minutes.
Dick Friedman personifies another behavior of champions that is extraordinarily effective. He allows himself to be the hero of the story – without anyone taking umbrage. He achieves this by discussing events of the past, “I did this”, rather than the future, “I’m sure I’ll be able to do this”. He sticks to the facts of the story. Most importantly, he lets the listener draw the conclusion, having carefully led us to the point where the conclusion is apparent. In the words of Dorie Barton from Connection, “Story is a set of details about a person’s (or persons’) experience, arranged in a deliberate structure, which gives it specific meaning and universal appeal. Story structure is a process in which a hero does something challenging in order to gain something useful.” Good stories have a hero.
Dick Friedman is our guide through a difficult topic, and he lets his passion for that topic show. He cares very much about heart disease. Every patient saved is a personal triumph. That is apparent when you hear him speak. As scientists, we have to accept that being the hero of an appropriately told story is a compelling way to champion science, and done with candor and humility, is never a personal aggrandizement. It is merely a demonstration of how much we love our topic, and how much we want others to share our passion.
1 e.g. Randy Olson, Dorie Barton and Brian Palermo, Connection (Los Angeles: Prairie Starfish, 2013) page 76.