Table Of ContentMedical Illuminations
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MEDICAL ILLUMINATIONS
Using Evidence, Visualization
and Statistical Thinking to Improve
Healthcare
howard wainer
National Board of Medical Examiners
1
1
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© Howard Wainer, 2014
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First Edition published in 2014
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Dedication
To the Yankees:
From Yogi, Mickey and Scooter,
To Derek, Jorge and Mo.
Sixty Years of Evidence
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PREFACE
I
t is rare to fi nd apostasy on the staid and dignifi ed pages of Th e New York
Times , and yet there it was, not once, but twice, prominently displayed in
the Sunday Review section on June 3, 2012.
On the fi rst page, above the fold, was an article by Elizabeth Rosenthal MD,
“Let’s (not) get physicals,” in which she lays out the evidence against the almost
canonized ritual of an annual physical exam. She points out that, “For decades,
scientifi c research has shown that annual physical exams—and many of the
screening tests that routinely accompany them—are in many ways pointless or
(worse) dangerous, because they can lead to unneeded procedures.” She then
goes on to list ten routine screening tests and medical procedures that research
indicates ought to be jettisoned.
Aft er recovering my breath I turned to the inside of the section to read the
continuation of Dr. Rosenthal’s article, only to be greeted by a second essay, by
Gary Taubes, a medical researcher at the Robert Wood Johnson Foundation,
explaining that evidence suggests that eating less salt can sometimes worsen
our health!
As I read these two remarkable reports I fl ashed back to a line in Woody
Allen’s 1973 fi lm “Sleeper” in which Miles Monroe, the lead character, aft er
awaking from a two centuries long nap, is off ered a cigarette and told “don’t
worry, it’s real tobacco; it’s good for you, like malteds and bacon.”
What happened to turn accepted medical wisdom on its head? Th e short
answer is “evidence.” But as evidence accrues to provide a convincing argument
for changing medical practice, another question emerges: if this evidence has
been around for so long, why has it taken until now for the suggestion that we
change practice? And, now that these results, garnered from scientifi c journals,
have progressed far enough to fi nd themselves in the popular media, why are
there still staunch defenders of the status quo?
Th ese puzzles, exemplifi ed in these two recent articles, are what piqued my
curiosity over the past few years and led to this book. In it I take a case-study
approach to explore a number of medical situations spanning the evaluation of
hip fractures, the value of mammograms, and the use of glucose meters to help
control diabetes. In the course of telling these stories I recognized that some-
times we have to go a little out of the way in order to come back a short distance
correctly. 1 And so the beginning of the book is a detour that examines both why
it is important for the medical care consuming public to understand oft en-subtle
evidence and how we might communicate that evidence better. One important
part of the answer to this are graphical displays. Surprisingly, I continue this
tale by introducing Will Burtin, a remarkable refugee from Nazi Germany, who
came to this country with little English but possessed of an extraordinary abil-
ity to communicate complex material in pictures. He spent much of his long
career working in medicine and a single graph that he produced provides the
raw material for a running start into my narrative.
But there would be no narrative at all without the cooperation and advice
I received from a fairly large number of my colleagues. It is my honor and my
pleasure to express gratitude to them now.
First, let me begin with Donald Melnick, president of the National Board
of Medical Examiners, whose leadership provides the resources, atmosphere
and encouragement for scholars to pursue extended projects like this one. He
also, when asked, dipped into his impressive medical memory to off er sugges-
tions about possibly fruitful paths. Next, my thanks to Ron Nungester and Brian
Clauser, who read everything that appears here, and much that, happily, does
not. Th ey also provided time and quiet.
Also, my gratitude to my collaborators on much of the work that was syn-
thesized into this book. I begin with my coauthors: Peter Baldwin, Joseph
Bernstein, Michael Larsen, Shaun Lysen, Sam Savage and Paul Velleman. Next,
I must thank colleagues and friends who off ered crucial help all along the way:
Steve Clyman, David Donoho, Bob Galbraith, Kyung Han, David Hoaglin, Peter
Scoles and Xiaohui Wang. Chapter 2 would have been very barren indeed with-
out the contributions of Jana Asher, Georgette Asherman, Jacques Bertin, Troy
Brandt, Mindy Chang, Pierre Dangauthier, Céline Dartois, Lawrence B. Finer,
Dibyojyoti Haldar, Benjamin and Katherine Lauderdale, Mark Nicolich, Philip
Price, Christian C. Ryan, Brian and Christine Schmotzer, Donald Schopfl ocher
and Justin Talbot.
Of course, I would never get anything done without the help and supervision
of Editha Chase, who takes care of everything; doing it so quickly and perfectly.
viii | preface
Special thanks to Drs. Marc Drimmer and Rachel Dultz for restoring to me a
treasure most dear.
Profound contributions are sometimes hard to pinpoint. My wife, Linda
Steinberg, reads far more widely than I do and tells me of many wonderful ideas
and facts that she has harvested. Her judgment has always been remarkable and
what I was able to retrieve from our conversations has enriched this story in
too many ways to recount. She also reads much of what I have written and her
suggestions have improved clarity and grammar, while subtracting pompos-
ity. I thank her for all of this; and for her permission to keep in some of the
semicolons.
Last, my thanks to the editorial and production staff of Oxford University
Press whose professional expertise helped me to more nearly say what I meant.
Primus inter pares among the many who added their professional expertise
are: Clare Charles, Gandhimathi Ganesan, Claire Hopwood, Keith Mansfi eld,
Victoria Mortimer and Penny Sucharov.
Howard Wainer
Pennington, NJ
April 2013
preface | ix
