When the Lights Go Out
What can reality TV teach us about clinical drug trials?
From the combined 17 seasons of ABC's The Bachelor and The Bachelorette—which regularly featured noisy declarations of on-air love—only a single marriage has emerged. Millions regularly tune in to Fox's American Idol, but the show that produced bona fide superstars Kelly Clarkson and Carrie Underwood also crowned Taylor Hicks, who last year was dropped by his label, Arista. The Fortune 500 has yet to include a winner of NBC's The Apprentice, and Anna Wintour has not featured an America's Next Top Model victor on the cover of Vogue.
Though it may seem a stretch, the lessons of reality TV can help us understand why, for example, many parents recently were told—with the suddenness of Jason Mesnick's dumping his fiancee Melissa Rycroft on the last Bachelor finale—that a large federal study contradicted its initial findings and concluded that drug treatment for attention deficit disorder had no benefit in children who were followed for six to eight years. These results put into question the widespread use of stimulants like Ritalin and Concerta, which were prescribed roughly 40 million times last year, and led to an acrimonious public debate among the study's co-authors.
Paul Bataldan, who co-founded the Institute for Healthcare Improvement, once observed that "every system is perfectly designed to get the results it gets." Reality TV participants desperate for fame or love sing (and lip-sync) shortened, preselected songs or go on over-the-top dates in fabulous locations, followed by a team of camera operators. The ostensible goal—the one declared to the audience—is to identify the most talented recording artist or most compatible couple. But as Bataldan might observe, the shows are instead designed to win over television viewers, which is an altogether different (and possibly incompatible) goal.
The parallels to a major clinical drug trial are uncanny. In the federal Multimodal Treatment Study, hundreds of kids with ADHD, whose families were desperate enough to enroll them in a randomized study, entered a well-funded and highly supervised National Institute for Mental Health program complete with specialized therapy, regular evaluation by developmental experts, and careful drug prescription—a setup that's about as realistic as a date on The Bachelor. Within that very unusual, closely monitored environment, as reported in 1999, stimulant medications caused modest improvement after about a year. In response, use of these products surged nationwide, and Ritalin and its peers became household brands. But in March, the researchers described what happened after the lights went out. In their subsequent years in the real world, the drug-treated kids ultimately ended up no better off than the others.
Epidemiologists call this the problem of "surrogate endpoints," and it's no surprise to fans of reality television. Garnering the greatest number of text-messaging votes after a brief performance doesn't always mean you'll be a successful pop star; winning the final rose after an on-air courtship doesn't mean you'll have a happy marriage; and getting higher scores on a simple rating scale of attention-deficit symptoms doesn't mean you'll later succeed in school. In medicine, this problem happens all the time.
Few drug-trial studies have the time or money to study the actual health outcomes that people care about, such as whether the middle-aged man avoids a heart attack after a few decades, the hyperactive first-grader holds down a good job someday, or the menopausal woman remains free from a hip fracture when she's elderly. Waiting for these events would stifle any meaningful innovation, so doctors pick surrogate endpoints, which they hope serve as short-term checkpoints. Thus drugs trials for the preceding examples may just decide to measure the middle-aged man's cholesterol level, the youngster's symptom checklist for hyperactivity, and the woman's bone density with a DEXA scan.
Darshak Sanghavi is Slate's health care columnist. He is chief of pediatric cardiology and associate professor of pediatrics at the University of Massachusetts Medical School as well as the author of A Map of the Child: A Pediatrician's Tour of the Body. Follow him on Twitter.
Photograph of Kris Allen on American Idol from YouTube. Photograph of Ritalin on Slate's home page by Joe Raedle/Getty Images.