An interview with Jerome Hoffman, MD, professor emeritus at UCLA.
Martha Rosenberg: As professor emeritus at UCLA (University of California, Los Angeles), you engaged in what is laughingly called in academics the “triple threat” of research, teaching, and clinical work for 30 years. Can you please summarize a little of what you did?
Jerome Hoffman: You’re right – I spent my career as an old-style academic, doing those three types of work. Virtually all my clinical work was in the emergency department. My teaching was much more widespread, both within and outside the university, and while it was centered in UCLA’s emergency medicine program, I taught much more widely, both at home and elsewhere. My research was a bit all over the place, but mainly in what is known as health services research.
Martha Rosenberg: You are known as a skeptic. Can you tell us a bit about that?
Jerome Hoffman: Sure. But let me start with a disclaimer. I do consider myself a skeptic, but certainly not a cynic. There’s a big difference. Today, we’re living in a time, and a country, where there is widespread distrust of “experts,” as well as of science. My challenges to received wisdom have never been based on that; they’re about distrusting bad science and false expertise.
When I was a trainee in the 1970s, we were expected to do what our seniors told us, no questions asked. Even asking, “Why do we do it this way?” was frowned upon … and we certainly couldn’t challenge something we were told. In that era, however, very little of medical practice was based on scientific evidence. And it was obvious to anyone who paid attention that at least some of what we were doing didn’t make sense. For example, when I was a trainee in internal medicine, we routinely got millions of lab tests and X-rays that everyone on our team knew were irrelevant to the patient in question – and we even frequently ignored “abnormal” results precisely because we knew they weren’t relevant. It was even worse if we didn’t ignore such red herrings – as they mostly led to a wild goose chase that could only hurt the patient. Similarly, a few years later, when I was a resident at the country’s busiest ER, I asked everyone I could whether we actually accomplished anything by putting a huge tube into the esophagus of the great many overdose patients we saw – standard practice everywhere at the time – but all I got back was “this is how we do it.”
To make this all worse, medicine was extremely hierarchical, and we were never asked, or even allowed, to think critically. I came to med school after graduate school in literature, where coming up with new ideas was how students got praised – so I was particularly unhappy with this very different view of “teaching.”
Martha Rosenberg: So how did you manage to begin challenging some of the things you were told?
Jerome Hoffman: That’s too long a story to go into fully, but five years after I finished med school, I met a teacher/mentor who approached medicine with intellectual curiosity, and he had a big influence on me. A bit later, shortly after I joined the faculty, I was asked by a colleague a few years my senior to give a brief lecture to local community doctors on “research methods.” The only problem was that I knew almost nothing about the topic … so I spent the next few weeks feverishly trying to educate myself. That started many years of work in this area, which ultimately became my academic specialty. In the short term, however, it merely began to make me realize that most of the “studies” I was reading in medical journals bore little relation to science.
Fortunately, the arrival of the “evidence-based medicine” (EBM) movement, a decade later, helped precipitate a change in all of this – although I think it’s equally likely that it coincided with other pressures to improve medical knowledge. In many ways, things are much better today, although unfortunately, they remain far from good. As an aside, I don’t want to get sidetracked into a discussion of EBM, but I do need to say that while I am an enthusiastic supporter (and teacher) of most of its basic principles, I am very critical of the way some of its most outspoken adherents have tried to transform it into a religion of sorts.
Martha Rosenberg: Getting back to your own work, did you eventually do research that challenged common practice, and if so, can you give us some examples?
Jerome Hoffman: Sure. Much of what’s published in medical journals looks at a proposed diagnostic or therapeutic process in terms of what good it might do … with a little after-the-fact (and in small print) concession to possible harms. But even if doing a CT scan, for example, in someone at low risk – “just to be sure” – picks up something occult, and dangerous, and (let’s say) saves one person out of a thousand, that’s not such a good deal if in the process you severely harmed three others. I did many studies looking at testing, in which we asked about both benefits and harms of testing and compared them. This often led to questioning what was widespread practice.
Martha Rosenberg: Is this the main reason you got your reputation as a skeptic?
Jerome Hoffman: Actually, I suspect not. As I mentioned before, I spent a lot of time studying and then teaching about how science is (or should be) done. For many years, starting in the early 80s, I co-hosted, every month, what we would now call a blog/podcast, in which two of us reviewed the latest and greatest medical literature. This program became quite popular and over time had lots of listeners – mostly because we kept the dialogue humorous, I suspect, but also, I hope, because listeners thought they were learning something. Unfortunately, the more I learned about ways in which research can be biased and therefore reach the wrong conclusions, the more often I talked about not just what the study claimed to prove, but why we shouldn’t actually believe it. Over time, I also got invited to many conferences and training programs to speak about such flaws in the literature. The single most cited journal article in medicine is entitled “Why More Than Half of What Is Published Is Wrong,” and once you understand how easy it is to do studies that are designed to reach a given conclusion – regardless of whether or not it’s the correct conclusion – it becomes equally easy to understand why that article title is accurate. And there is plenty of evidence that research biases and distorted results are particularly prevalent when the research is done by a company that’s trying to sell you something.
It’s also important to acknowledge that such drivers of bad science, leading to bad practice, are not merely because of companies that have an ulterior motive. We could spend a lot of time talking about the biases of major medical journals, that get a huge part of their budget from industry, and of academic programs at what is often called “University Inc.” because of the huge income they get from doing proprietary research, and even of government agencies that are often appropriately characterized as handmaidens of industry.
Martha Rosenberg: You’ve written and spoken a good deal about overdiagnosis – which is another area where you appear to have challenged conventional wisdom. Please tell us about that.
Jerome Hoffman: Sure. I must first say that I think “overdiagnosis” is a slightly unfortunate term since most people think it’s talking about false positives – where a test suggests a condition that isn’t really there. But what is called overdiagnosis actually refers to a test that is true positive – it diagnoses a condition that is there. The problem, however, is that these days when we diagnose something that in the past we always thought of as dangerous, it might not actually pose much, if any, risk. This is in part because many modern technologies can find “more and more of less and less,” and in part because we have recently become fixated on “finding a disease early,” using screening tests, and a “disease” found by screening is very different than that same disease when it’s diagnosed in a patient who is already having worrisome symptoms.
When we do a screening test, we’re looking at a general population in whom the disease is not common and among a group of people none of whom seems to be at particular risk. So if we’re looking at a group of 10,000 people in whom only one has the disease, we can only possibly help that one person, while that screening test could conceivably lead to a cascade of events that could hurt all 10,000 of them. And even if it’s an unusually accurate test, with very few false positives and false negatives, there is the problem of overdiagnosis.
Prostate cancer screening is probably the poster child for this concept. When an autopsy is done on an 80-year-old man who has died from something else, that has nothing to do with his prostate, there’s about an 80 percent chance you’ll find cancer cells in his prostate. The chance goes up to about 90 percent in similar 90-year-old men. That is to say, all these men died with prostate cancer, rather than from it. They never knew about it and suffered no consequences because of it. But had the “cancer” been IDed while they were alive … they would undoubtedly have been subjected to lots of further testing and “treatment” – from which a good many of them would surely have suffered substantial harm.
Martha Rosenberg: So you are saying that such a prostate cancer could be ignored –– it was not lethal or terminal?
Jerome Hoffman: Well, it’s hard for a patient to ignore something that’s been labeled cancer. But yes – from a benefit/harm standpoint, finding such “true” but almost always harmless “disease” would almost certainly do more harm than good. That’s why some of us believe the trick is to avoid looking for true positives that are actually overdiagnosis in the first place.
I need to emphasize that this is extremely different for clinical prostate cancer, discovered on diagnostic, as opposed to screening, testing. Clinical prostate cancer is a major cause of morbidity and mortality, and when it’s found in a patient with worrisome symptoms, it should never be ignored.
Overdiagnosis and its attendant capacity for harm is also surely true not only for many cancers but also for a lot of other conditions. For example, we probably all have tiny blood clots in the arteries of our lungs. Indeed, one of the physiologic functions of our pulmonary arteries is to weed out little clots before they can cross over to our systemic circulation and cause a terrible problem like stroke. So tiny clots are normal and generally no big deal. But now that we’ve got very sensitive tests, like CT scans of the chest, that can find these little clots, we’ve dramatically increased the number of diagnoses of “pulmonary emboli” (PE) that we make. Unfortunately, we confuse these diagnoses – often made in patients who are at most minimally symptomatic – with the diagnoses of PE we would, in the past, only look for, and thus only make, in patients who were clinically very sick. So it’s not surprising that excellent studies demonstrate that the overdiagnosis of PE has not decreased the number of deaths at all, but it has increased the harm from vastly increased “treatment.”
Martha Rosenberg: Better technology is a mixed blessing?
Jerome Hoffman: Yes – at best, to my mind. People say, “Well, wait until we get better technology: that’ll clear it up. You’ll be able to tell what’s good and what’s bad.” I believe it’s actually the opposite. If we had an electron microscope CT, we’d undoubtedly “diagnose” everyone as about to die from umpteen different “diseases” – that should actually be understood as overdiagnoses.
Martha Rosenberg: What role, if any, do drug makers play in overdiagnosis?
Jerome Hoffman: A big one – and in various ways. There’s a wonderful book by Ray Moynihan that addresses in detail what he insightfully calls “the creation of disease.” But all you have to do is watch a few of the zillions of pharma ads on TV to know what that is about. Of course, pharma doesn’t only influence patients; it also spends a fortune on lobbying. But I have been most interested in the ways it influences doctors.
Martha Rosenberg: Tell us more about that.
Jerome Hoffman: Way back in the early 1980s, I joined a group called No Free Lunch, which addressed the influence of so-called gifts – like “free” lunches [from the pharmaceutical industry], which were commonly provided to doctors in those days by drug reps.
At the time I gave my first talk on this subject, to a noon conference of residents and students, I noted that once you take something from someone, it inevitably leads to cognitive biases that will influence your behavior in ways that may not be defensible medically. But the residents, with whom I otherwise had a great relationship, were obviously quite unhappy not only with what I was saying but with me as well.
Martha Rosenberg: Why were they upset?
Jerome Hoffman: In those days, residents were vastly overworked and didn’t get paid a lot –– that’s still true today, but it was much worse then. So they challenged me, saying, “Why are you telling this to us? The faculty take much more from drug companies, and they need it a lot less than we do.” I agreed, of course, and let them know that if given the chance, I’d certainly say the same thing to the faculty. Which I did subsequently get to do. Those residents felt attacked, but fast forward 20 years later, and now 40 years later, and it is students and residents who are the biggest advocates of the “no free lunch” idea.
Martha Rosenberg: I remember reading a survey about financial conflicts of interest and doctors tended to think money affected other doctors but not them.
Jerome Hoffman: Yes, most of us can convince ourselves that we are immune to things that influence others. Just like so many people claim that they personally always win at Vegas. Hmm – I wonder how the casinos stay open!
I have been accused from time to time of being “holier than thou” when I talk about this. But the truth is just the opposite; if I felt holy, I would claim that despite the evidence that “gifts” – large or small – create obligations among the people who get them, I could resist and stay pure. In truth, I know that I am no different than the rest of us – so the only way I can avoid being influenced is to resist the temptation in the first place.
There’s a great story along these lines involving the former surgeon general Dr. C. Everett Koop. He was a grandfatherly pediatrician who rightly got credit for taking on the cigarette industry – despite the wishes of his bosses in the Reagan administration – and helping break its stranglehold on Washington.
After his time as surgeon general, he started a very popular website, in which he billed himself as America’s trusted doctor. One time that site anointed what he called the 40 best health care systems in the U.S. … but neglected to mention that each of the 40 had paid him $40,000. When he was asked if taking more than a million dollars would bias him, he was affronted; that much money might influence others, but not him. “I am C Everett Koop. I am an icon,” he said, rather memorably.
Martha Rosenberg: I can understand how a large “gift” can change behavior, but a pen?
Jerome Hoffman: Small gifts can be as or more powerful even than large gifts, because of something called cognitive dissonance. If you take a fancy vacation or lots of money in payment for making a company happy by pushing its product, you may feel “they’re not using me – I’m using them.” But no one wants to think he or she can be bought for a pen or a lunch. So when you are persuaded by their gift – and the friendship of the drug rep that invariably accompanies that gift – to prescribe their drug or to try to convince your colleagues to use it, you first have to convince yourself, subconsciously, that it really was the best medical choice.
And something like friendship really is the key to why taking something – even a pen – leads us to change our behavior. At one time I would occasionally read a drug company magazine written for their employees, and I often saw articles telling the employees that “your job is to make the doctor think you’re his best friend.” But at the same time, they would remind the employees that they must not see the doctor as their own friend.
I would often get laughs when I talked about this to a large audience of doctors when I would ask, “How many of you know of an ugly drug rep? Or an unpleasant drug rep?” The New York Times once reported that drug companies were targeting cheerleaders as future employees; I suspect that was not because of their scientific expertise.
Martha Rosenberg: What about yourself? How have you avoided the so-called free lunch?
Jerome Hoffman: When I was just starting out, we had no way to treat paroxysmal supraventricular tachycardia – PSVT. But then the drug verapamil was shown to work extremely well for PSVT, with minimal risk, for a reasonable price. Not too long after that, we started hearing about a different drug that was being aggressively marketed for PSVT. But it was far more expensive and routinely caused severe chest pain. And then along came a study comparing the two drugs, which showed that verapamil was also much more likely to work!
So when I was invited to give a talk on the latest and greatest medical literature to one of the regional medical associations, I included this paper, after which I opined that I couldn’t understand why anyone would use the less effective, much more unpleasant, and more expensive alternative.
As was common back then, there were drug reps exhibiting their wares close to where we talked. After the talk, a very nice-looking and well-dressed young man came up to me and started gushing about how much he enjoyed the talk. Needless to say, I was quite flattered. Then he gave me his card and told me that he worked for the company that makes verapamil, and asked if I would like to join their speaker’s bureau.
As soon as he asked that, a red flag went off inside of me. Up until that moment, I had thought it would be great to be on a speaker’s bureau, and get free travel to nice places, and even get paid! But standing next to that very friendly young man, I couldn’t help thinking, what about if I believe their next drug isn’t any good? Would I be able to say so? So I ultimately declined, of course. That was the moment I realized that if I wanted to be honest and honorable, and beholden only to what I actually believe, I couldn’t take anything from industry. I’m really grateful, in retrospect, that this was made so clear to me in that moment.
Martha Rosenberg: You have lectured all over the world and done sabbaticals at the University of England, in France, Tokyo, and Santiago, Chile. Is there any specific region or country whose medical infrastructure or advancement surpasses others you have seen?
Jerome Hoffman: That’s a huge question, and I don’t want to over-generalize based on my own anecdotal experience. But I will note that health outcomes achieved in the U.S. are fairly awful, even though we spend at least twice as much on health care as anyone else, and despite the fact that our medical education system, our resources, and our technical capacity to do very high-end stuff is certainly second to none. In its prior version of the health Olympics – looking at outcomes including overall mortality, infant and maternal mortality, access to care, and cost of care, etc. – the Commonwealth Fund ranked the U.S. 37th, which was pretty shocking. Until, that is, they just revised their ranking … and we dropped to 71st!
Martha Rosenberg: That is shocking.
Jerome Hoffman: Now, to be fair, part of that is due not to health care but rather to what’s called the social determinants of health: inequality, racism, poverty, housing and food insecurity, drugs, gun violence, etc. Those SDoH predict health outcomes more than health care does. Of course, the fact that we do so poorly in terms of those social determinants shouldn’t make Americans feel better. Still, these problems are exacerbated by our failing health care enterprise, which should actually be called a health care market, not a health care system. I spend a lot of my time these days trying to educate people about why we would do so much better if we created a national single-payer health care system, like that found in just about every other rich country.
I don’t want to pretend that single-payer would fix all these problems, even though it would help a lot. If we really want to fix things, we’ll first have to move away from a profit-driven health care model, and treat health care as a human right, rather than a commodity. And even better, we’d have to go further upstream, and address things like the massive income and wealth inequality in our country, which is also off the charts compared to most other wealthy countries. But those are huge topics for another day, perhaps.
Martha Rosenberg: In closing, would you like to offer three “take-aways” for doctors and medical students?
Jerome Hoffman: First, health care in our country is broken terribly –– it’s about profit, not health. Being a doctor was a wonderful profession for me, but today many are leaving because of what I call moral injury – they feel unable to do what they believe is best for their patients because they feel forced to act as ciphers whose job is most of all to check off the boxes that will maximize billing, as efficiently as possible, without “wasting” too much time with a patient.
My job as a teacher was not to teach facts, but to teach students to think critically. So my second message is that we shouldn’t believe something just because a learned authority says it’s true. Even when it’s a government agency, or a university, or a famous medical journal, or a “patient advocacy group” – all of which may actually act as handmaidens of industry. It’s not that government or regulation are “bad,” but rather that captured government and captured regulatory bodies are bad. Our job is to be skeptical, but also to work to fix what’s broken.
Finally, I would like to stress the responsibility that comes with being part of a profession. Sociologists tell us that there is an “unwritten contract” between a society and its professions, in which professionals are well rewarded, with good incomes and prestige and (most importantly) autonomy, in return for which we pledge to use our special knowledge – that our society needs but can’t get by itself – in a way that puts the public’s needs first. In medicine, that means, of course, that we must put the patient’s need ahead of not only our own but also ahead of the insurance company, or hospital, or whoever else it is that is paying us.
Martha Rosenberg is a health reporter and the author of Big Food, Big Pharma, Big Lies and Born With a Junk Food Deficiency.
