In my last post I described a story that appeared in The Lancet: A woman with many risk factors for a life-threatening blood clot developed a clot, a deep vein thrombosis (DVT). In addition to her many risk factors, she had been eating grapefruit for the previous three days. Here's how the media covered the story.

The most responsible headlines

I collected the available news stories on this incident from Google News in early April. All but one featured grapefruit, which is, after all, the only thing that makes this story newsworthy. Here are the most responsible headlines:

"Grapefruit, birth control pill interaction may have caused weird blood clot case" (The Canadian Press)

"Grapefruit May Have Raised Blood Clot Risk in Unusual Case" (Medical News Today)

"Grapefruit Breakfast Shares Blame in Leg Thrombosis" (Modern Medicine)

"Hunt for DVT Cause Reveals Link to Grapefruit" (Medpage Today)

"All things in moderation" (phillyBurbs.com)

The Canadian Press, which did follow-up interviews, and Forbes.com had the best coverage. Forbes had an unfortunate headline: "Grapefruit-Heavy Diet Helped Spur Dangerous Clot." The diet wasn't grapefruit heavy. As I've mentioned before, journalists are often not allowed to write their own headlines. The subhead was much better: "The fruit, combined with contraceptive pill and a genetic mutation, almost cost woman her leg, doctors say."

A few months ago, in a post on medical journalism, I noted: "The unstated assumption ... is that 'scaring the bejesus out of people' is a recognized journalistic practice when it comes to health news." This post describes a medical case in which grapefruit played a minor role. The next post illustrates how the media turned this innocent, everyday item into an object of fear.

The British medical journal The Lancet recently published the case report of a 42-year old woman who developed pain in her low back, left buttock, and left leg after a 90-minute car trip. The next day, when her leg had turned purple, she went to an emergency room. She was light headed, short of breath, and had difficulty walking. Her medications included Levothyroxine (Synthroid) for low thyroid levels and birth control pills, the estrogen/progestin combination type.

On examination, the woman was found to have a blood clot in her leg, a deep-vein thrombosis (DVT) that extended from her hip to her calf. What makes this story of interest to physicians is not the diagnosis, which was obvious, but the etiology: What caused this woman to have a DVT?

Among those opposing Obama's choice of Sanjay Gupta as the next Surgeon General is Adrian Campbell, a Michigan woman who appeared in Michael Moore's film Sicko. Gupta told his television audience:

In Canada, you can be waiting for a long time. A survey of six industrialized nations found that only Canada was worse than the United States when it came to waiting for a doctor's appointment for a medical problem.

In the film, Mrs. Campbell takes her daughter to Canada for an ear infection. She feels personally offended by Gupta's statement. "When Dr. Gupta said that Canada has longer waiting times, I felt like I was being made fun of."

Michael Moore got some valuable publicity out of this controversy. CNN's Wolf Blitzer interviewed Moore shortly after Sicko was released. Since the movie was newsworthy, Moore may not have expected an attack. But preceding the interview was a prerecorded "Sicko Reality Check" by Gupta. It was overwhelmingly negative and accused Moore of "fudging the facts." Moore responded with his characteristic forcefulness. CNN subsequently arranged a debate between Moore and Gupta on Larry King Live. (See Sources below for links to the Blitzer interview and the three segments of the debate.)

Back in November, following a two-hour meeting in Chicago, president-elect Obama offered Sanjay Gupta the position of Surgeon General. (This from a presumably reliable source: Gupta's mother, Damayanti.) Gupta has been prudently tight-lipped about the appointment ever since the Washington Post broke the story in early January.

Gupta, the chief medical correspondent for CNN, discussed the situation with his employer in mid-December. He no longer covers health policy stories for CNN, but he can still be seen on "House Call," his weekend health and wellness feature. When a plane crashed into the Hudson, CNN called on Gupta to discuss hypothermia, and when Senator Edward Kennedy collapsed at the post-inauguration luncheon, he was similarly "pressed into duty."

The majority of press coverage has been favorable. Ezra Klein, in a "Momma said wonk you out" column, says the 1993 Clinton healthcare reform failed because it didn't have a media strategy. The selection of Gupta signals that the Obama administration realizes it needs "a far more sophisticated media operation."

On the other hand, Fox News refers to Gupta as "the TV doctor," as if he were a cast member of General Hospital. Michigan Congressman John Conyers, a strong supporter of universal health care, opposes the nomination. He's promoting Dr. Herb Smitherman, a public health advocate from Detroit.

There's also support for Dr. George Lundberg as Surgeon General. Lundberg, a surgeon like Gupta, was the longest-running editor of JAMA, the Journal of the American Medical Association (17 years). He was abruptly fired by the AMA when he chose to publish the research article "Would you say you 'had sex' if...?", a survey on the definition of "having sex" among college students. The offense was not simply the subject, but the timing. The publication date of the article was January 20, 1999. The Monica-Lewinsky-inspired impeachment trial of President Clinton had begun on January 7. Lundberg was fired on January 15. The AMA, of course, did not cite this incident as the reason for firing Lundberg. (For those curious about the results of the survey, see the footnote below.)

Lundberg, the author of Severed Trust: Why American Medicine Hasn't Been Fixed, has a lot to recommend him. See the extensive commentary on the post "Dr. George Lundberg for Surgeon General" on The Health Care Blog (THCB). One thing I don't see mentioned at THCB is that Lundberg's appointment would be a slap in the face to the AMA, assuming 10 years isn't long enough to let bygones be bygones. Such lack of diplomacy would be highly uncharacteristic of Obama, who strikes me as a Nine on the Enneagram.

The Enneagram is a spiritually based personality typing system, associated with Gurdjieff, Oscar Ichazo, and Claudio Naranjo. Type Nine on the Enneagram is called the Peacemaker. Since I'm a Nine myself, my opinion on this is highly subjective.

Here's a cartoon about the nine Enneagram types that I think illustrates how we tend to see in Obama what we value in ourselves. That's a good quality in a leader. If Obama thinks Sanjay Gupta is the right choice for Surgeon General, I'm inclined to agree.

Barack Obama Supporters Come In All Types

Cartoons by Elizabeth Wagele

Footnote: Would you say you "had sex" if...?
The JAMA article doesn't say this, but one conclusion you could draw from the survey of college students is that they make a distinction between sexual activity that can lead to pregnancy and behavior that leaves one technically a virgin. The research survey was done in 1991 at a midwestern college and included students from 29 states. Close to 80% considered themselves moderate to conservative politically. Sixty percent reported that what happened between President Clinton and Ms. Lewinsky does not qualify as having "had sex."

The medical purpose of the survey was to ensure that public health officials are gathering accurate information relevant to disease transmission. The sexual activity with the greatest risk of transmitting an HIV infection did not qualify as having "had sex" for 20 percent of those surveyed. In a situation comparable to that alleged between Clinton and Lewinsky, 75 percent of students would not list the other party as a sexual partner. (This latter statistic is from a later (1996) survey.)

There was a widely reported story today about hormone replacement therapy (HRT) and a decrease in the size of women's brains. The headlines were predictably but needlessly sensational. In fact, the study did not measure a decrease in the brain size of any individual woman.

First, the headlines. There were 27 stories listed when I checked Google news this afternoon. 19 of these (70 percent) used the word "shrink," definitely a frightening choice of words when talking about one's brain. Five stories (18.5 percent) used a less provocative descriptor: brain-tissue loss... reduced brain size... reduction in brain volume... affects brain mass... loss of brain tissue... You get the idea. Three stories (11 percent) elected not to refer to brain size in the headline. But two of those talked about brain "shrinkage" in the first paragraph, another waited until the third. So all of these stories led you to believe that the brains of women on HRT got smaller.

The rush of stories was based on two papers published in the January 13 issue of Neurology. The primary paper analyzed brain scans for abnormal tissue (lesions) in blood vessels. The second paper analyzed MRIs of the brain and reported:

Much to our surprise, we found a small but significant decrease in the hippocampal and frontal volumes, and a nonsignificant trend towards reduced total brain volume in women who had been randomized to hormone therapy.

I haven't had an opportunity to see the original study, but none of the quotations I have seen use the word "shrink."

Do you eat trans fats and high-fructose corn syrup? If you know the ingredients of what you're eating, you can choose to avoid certain foods. But what about the consumption of health news? There is an enormous appetite for the latest medical findings, but no labels to tell us the ingredients: how are the stories selected, what are the sources of information, how accurate is the reporting. If we knew the ingredients, would we choose to avoid the majority of stories on medical research and health? In this post, I'll discuss the ingredients of health news and, in the next post, I'll suggest a reliable source.