Below, a guest post from reader Jim Jaffe writing at Centered.Politics.com
Let me add only that the President Obama’s fiscal stimulus package is funding comparative effectiveness research with an eye to finding the best treatments for patients who meet a particular medical profile. This research will not lead to “one size fits all” medicine.
Moreover, just as in the UK the research will be used to create “guidelines” not rules. In the U.K. physicians follow the guidelines about 89 percent of the time—which seems about right. There are always going to be cases that don’t fit the guidelines, particularly when patients are suffering from two or three chronic diseases.
Finally, it is likely that both Medicare and a public sector insurance plan will begin raising co-pays—and lowering fees—for unproven treatments which as Jim points out, “just aren’t working.” In this way, public sector plans can steer both patients and doctors toward more effective treatments. (Private insurers are likely to follow suit.) At the same time, President Obama has made it clear that his administration wants to raise fees for primary care physicians who spend time talking to patients, listening to them, and managing chronic illnesses.
When Evidence Meets Pluralism
By Jim Jaffe
Surprising resistance to the embrace of evidence-based medicine as part of health reform reflects a fear of binary and bureaucratic government regulations that ignore the dynamic nature of science. Some of these objections are defensive, but they nonetheless deserve a respectful and honest response, lest they fester to a point where they jeopardize progress.
I’ve encountered three separate expressions of concern. The first was from conservative elements cable news/blogosphere community which predictably warned that the government was going to come between patients and their doctors and second-guess therapeutic decisions in an effort to save money. The others came from physicians. One is a psychiatrist who argues that every patient is unique and merits a unique response. The other argued that there’s a danger research results will be imposed too widely as results are taken too seriously too soon and thus fuel today’s escalation of ineffective and expensive care.
These arguments have merit, particularly if we’re truly moving toward a government-written rule-based cookbook that draws crude, bright lines that will only allow women over 47 to get a mammogram irrespective of personal circumstances. It isn’t clear whether any of the reformers truly want to go there. Doing so would be a mistake.
But adopting the pluralism that governs other elements of our political life seems sensible. We license drugs, but allow providers to select which is most appropriate for a particular situation.
As economist and budget expert Alice Rivlin recently noted, we need a way to sensibly limit treatment options – an absolute necessity if we’re to squeeze out the estimated 30 percent of treatment dollars that are wasted – without being unduly restrictive.
A recent article in the New York Times documented our addiction to unproven treatments, citing evidence that standard treatments for heart attacks, osteoarthritis and ear infections simply don’t work and can cause harm to patients.
Why do we continue to push hospitals to administer beta blockers to heart attack victims when the studies show – by a score of 26-2 – that it doesn’t do any good?
Why do a half million Americans get knee surgery every year – at a cost of $3 billion – for a problem that the surgery apparently doesn’t help? Patients subjected to sham surgery are just as happy with the result.
Why do a similar number get back surgery – which costs $20 billion – when non-surgical therapies do an equally effective job of reducing pain? Such questions posed by reformers demand answers.
Spending money on efficacy research isn’t a good investment if the results have no impact. Imposing rigid rules based on such research doesn’t make sense either. It isn’t good politics or good science, both of which are fluid and change over time.
This point was driven home in a recent blog where the Mayo Clinic, widely perceived as efficient and evidence-based, was criticized because of a failure to embrace procedures that another health system had deemed evidence-based. Implied was a Gold Standard of Evidence that everyone would follow – at least until it changed, which happens quite frequently on issues ranging from estrogen replacement to PSA screening to mammograms to use of statins.
The fact that Kaiser and the VA and Mayo come up with slightly different results based on the way they screen the evidence doesn’t trouble me. What’s troubling is that many providers are not using similar scientific techniques to screen what works. So they continue to prescribe antibiotics for ear infections, ignoring evidence that they’re more likely to harm than help.
Conservatives who want to maximize personal – and provider – freedom tend to argue that transparency is the answer. Make the research available to all and let the people decide. But the people lack the sophistication to decide. That’s why we rely on medical professionals with expertise. If we patients were able to make competent decisions, the unemployment rate among physicians would soar. That won’t happen anytime soon.
There seems to be a broad consensus that the current policy where virtually anything goes – and is reimbursed – isn’t working well. In a culture where more is often seen as better, encouraging patients to push their providers toward less expansive remedies is an uphill sell. That explains part of the negative reaction to managed care. The issue here is how to impose sensible parameters on care that patients will not only accept, but derive a certain comfort from.
Finding a middle way – which is the hallmark of our political system – where providers rely on evidence that guides them among viable options without being unduly restrictive, will be a major challenge as the process moves forward.
I agree with what Jim is saying in regard to concerns about practice standards, and with his and Maggie’s observations that many of these are not valid, but that the system needs to incorporate some degree of flexibility to allow for exceptions to the rule.
However, I want to emphasize the fact that evidence based practice standards stand alone as a way of saving the amounts of money needed to ensure the operation of an ethical and effective health care system in the US.
Savings are possible in other areas — we have talked about decreased compensation for highly paid specialists, savings from more efficient administration, potential savings from the EMR, savings from negotiating prices for drugs and equipment, cutting expenses of hospitals and other health care systems on luxurious physical plants and highly paid executives, and so on. All those steps should be adopted, since each makes a contribution to lower costs. But as I have said before those savings are not enough to make the system work without cost containment related to standards for effectiveness of care.
In the end, we have a stark choice: save money through practice standards or save money by cutting coverage for most Americans. I hope we have the sense to choose practice standards, since they would result in better, not worse, care for most Americans.
Be sure to read Dr. Grace Jackson’s “Open Letter to the Federal Coordinating Council for Comparative Effectiveness Research” posted on the Institute for Nearly Genuine Research web site:
http://www.bonkersinstitute.org/jacksonletter.html
Unproven and ineffective has never been a criterion for rolling back any number of failed regulatory schemes from CON’s, to DRG’s to HMO to P4P to never events (like falls which have resulted in patients restrained to their nursing home bed to avoid the paper work involved in a fall.)
The people don’t have the sophistication to decide? (I guess better get them off malpractice juries.) Do our want-to-be overlords have the requisite sophistication? A little bit of knowledge, a lot of political orthodoxy and absoulute power is going to be a very toxic combination.
For me this all hogwash. The simple truth is a a fight for power. Who is going to control healthcre? Before the seventies it was the medical profession, then came the goverment and the insurers with their large Ponzi schemes(The don’t invest or manage risk!). Now after creating a large administrative burden and failing to reing on greedy lawyers they are going to figth it out. Neither the insurers not the goverment can diagnose or do surgery. Yet they want to control it and the results are not going to be good! 59% of primary care physicians are in small practices(3 or less doctors) They want to practice evidence base medicine but the can’t if they want to survive in the current environment. The Medical Home requires a large investment on IT and more administrative staff. Given that the majority of primary care physicians are in baby boomers with paper charts, no amount of incentives is going to take them out of their comfort zone into large practices. In two to five years most medicare patiatens will end up in the emergency room sharing stories with the medicid population. Get the primary care physicinas involve they are the solution not the problem!
Practice guidelines start as a tool for us docs and end as a club for our overlords.
Great site and I am really pleased to see you have what I am actually looking for here and this post is exactly what I am interested in. I shall be pleased to become a regular visitor
In a report by Twila Brase, president of the Citizens Council on Health Care, she challenged evidence-based medicine.
Evidence-based medicine (population-based evidence) has become a euphemism for managed care, masquerading as science (or profit-maximizing in the guise of science). Control over medical decisions are shifted from doctors to bureaucrats in big offices. Managed care organizations use it to solidify their control over medical decisions and the practice of medicine. Instead of explaining their decision by saying the service is not necessary or not cost-effective, they can say it is not scientifically sound.
Individual patients are not the focus of evidence-based medicine and its standardized practice guidelines. The guidelines are created by accessing private medical record data, aggregating the data, and synthesizing it into population-based treatment algorithms for all physicians to use on all patients. In other words, bureaucratized medical practice.
Evidence-based medicine results in overly rigid standards of care by restricting medical practitioners’ professional freedom and judgment. It imposes personal agendas by those choosing which research to do, picking between the various studies and calling it evidence, while writing all the guidelines, as well as administrative bias by administrators interpreting the guidelines.
The guidelines often fail to make explicit how recommendations are devised and they rapidly become outdated. Even the “evidence” is suspect. Researcher bias, disagreement in defining best evidence, incomplete reporting of research results, and conflicting findings are some of the problems with research relied on for determining “best practices” or evidence-based medicine.
There are gaps and inconsistencies in the medical literature supporting one practice versus another, as well as biases based on the perspective of the authors, who may be specialists, general practitioners, payers, marketers, or public health officials. Evidence-based medicine changes what it considers to be science in order to suit the goals of its proponents.
Evidence-based medicine is not an objective, purely scientific tool its name suggests. Instead, it is an intrusive encroachment on the patient-doctor relationship and the practice of medicine. An encroachment that policy makers are turning into legal requirements.
As usual, many US opponents of health care reform are ignoring the presence of a large body of experience with scientifically based practice standards in the rest of the world in order to create a fantasy about practice standards to attack.
Practice standards are an important part of health care management in every other developed country. The standards are not manufactured by faceless bureaucrats but rather by panels of well known physicians working within their own fields of specialty. They do allow for exceptions for individual situations if the health provider can show that patient’s condition suggests it – in Britain the average compliance is only 89%. Doctors in those countries have few complaints about the process.
Most importantly, the countries that follow these policies actually have better results of health care than the US system of greater freedom of action does.
Even in the US, the centers with the best performance in the Dartmouth data and other similar studies frequently employ institutional standards of care that allow them to attain better and less expensive results of management.
In fact, many of the standards employed in other countries are based on studies performed in the US and recommendations conceived in the US, but too often not followed here. The results of the multi-center study on management of high blood pressure and the subsequent study demonstrating very poor conformity with the recommendations of the study is one example.
To be clear, we are not talking about standards for managing unusual conditions. No one is proposing standards for rare cancers, unusual medical conditions, or rare genetic defects.
The proposals largely cover very common conditions that account for the overwhelming percentage of health care. Congestive failure, coronary artery disease, chronic lung disease, asthma, diabetes, kidney failure, GI diseases, common types of trauma, back pain, depression, and so on. They also apply to common types of procedures: placement of central lines, ventilator management, isolation precautions, drug dispensing, pre-surgical planning, etc.
These things account, in study after study, for a huge majority of health care encounters, ER visits, hospital admissions, ICU admissions, and health care costs.
These are not mysterious problems that are poorly understood or embroiled in scientific controversy. They are very well studied and understood. However they remain problems for management, accounting for the lion’s share of readmissions and therapeutic failures.
Study after study shows that careful application of well understood principles will improve the management and results of these conditions, but also shows that these principles are too often ignored.
Health care management standards offer the opportunity to fix these problems to the benefit of everyone, with no more impingement on doctors’ independence than is already typical in medical practice.
Good doctors use “evidence” – information tending to establish a fact – to treat individual patients. Good medicine depends on tacit, or contextual, knowledge in that relationship.
EBM adds nothing. It creates an unjustified taxonomy of investigative processes whose relative merits depend on the question being asked. It is nothing to do with their intrinsic merit.
The results are appalling.
(1) EBM guidelines rapidly become regulations.
(2) Doctors feel obliged to use them, not their judgment.
(3) Inexperienced doctors never learn anything other than “guidelines”. They lack confidence in their judgment.
(4) Clinical research is reduced to subservience to guidelines.
(5) All kinds of bodies arise to produce and promote (conflicting) guidelines.
(6) Doctors are evaluated against guidelines
(7) There is little evidence that guidelines help patients.
(8) The arch-proponents of EBM have fled the UK – having understood their problems – though the bureaucracy have embraced their legacy of “command and control”
North American medicine can do without them – they will cause mayhem.
The argument here is between “clinical experience” and research.
All doctors are trained based on the results of research, and always have been. The methods we are taught for approaching and treating patients are all research based.
The question is what is superior – the personal judgment and experience of the practicing physician or the results of research.
The pattern for practice in the US is use of personal judgment. Obviously, this judgment is augmented by exposure to additional information, but in the US a disproportionate amount of this added information comes from small, non-randomized and essentially non-scientific research results that are basically preliminary studies and from information offered by stake-holders in various approaches – drug companies, equipment companies, and academic physicians involved in the development of the techniques.
As a result, we overuse some types of management that are ineffective, more costly than other approaches that are as effective or more effective, or outright harmful to patients.
Most other countries have found this approach to be inappropriate and unaffordable. They have developed practice guidelines intended to push providers toward more effective and more cost-effective approaches. In the process, they have saved money and have enjoyed better clinical results.
Obviously, there are many areas of medical practice where data is unclear. It is not appropriate to develop guidelines in these settings.
Fortunately, the areas where the evidence is most clear often coincides with the areas of medicine that involve the largest numbers of patients, the most admissions to hospital, and the most common illnesses.
Application of guidelines based on data in these cases has led to better care elsewhere, to better care in the US where they have been employed, and would almost undoubtedly lead to better care if more widely employed in the US. And they have saved large amounts of money, both elsewhere and where employed in the US.
In the end, the “appalling” results have been a significant improvement in health care results, better health and better quality of life, and lower costs. This has been obtained at the expense of some doctors feeling that their independence and self-image has been impaired, although many doctors are happy to practice in that type of setting and pleased with the results. To me, a small impingement on the egos of some doctors seems a very small price to pay.
Fred Smith, Pat S., Gregory,
Thanks for your comments.
Fred Smith-
First, welcome to the blog.
I have to disagree with what you say about guidelnes. It’s esstntial that they are guidelines, not “rules”. As I noted, in the UK doctors follow the guidelines only about 89% of the time, which seems right.
The Mayo Clinic in Rochester, Minnesota uses guidelines, and the DArtmouth Reserach shows that it offers some of the most effective care in this country–at a lower cost than most medical centers. Meanwhile, patient satisfaction and doctor satisfaction are much higher than average.
But at Mayo, a doctor can deviate from the guideliles–he just needs to indicate, in the patient record, what caused him to decide that another treatment would be better. This allows other doctors to learn.
No one wants young doctors blindly following gudelines.
Also, in the UK, and in the US where medical centers use guidelines, they are constantly being revised as we learn more . . .
At the same time, I think that using guidelines becomes very tricky when a patient is suffering from 3 or 4 chronic diseases. . .
I plan to write a post about this.
Pat S.
You write: “Study after study shows that careful application of well understood principles will improve the management and results of these conditions, but also shows that these principles are too often ignored.
I agree. My only caveat is , as noted above, when a patient suffers from three or four common, chronic conditoins, using guidelines becomes complicated. Probably we need more reserarch on how to handle patients suffering from the five most common chronic diseases.
Reader Brad F. called my attention to this problem–
I plan to write a post about it. . .
Gregory–
You write: “medical decisions are shifted from doctors to bureaucrats in big offices. Managed care organizations use it to solidify their control over medical decisions and the practice of medicine. Instead of explaining their decision by saying the service is not necessary or not cost-effective, they can say it is not scientifically sound”
I don’t think Jim is talking about “evidence-based medicne” where the guidelines are set by for-profit insrance companies.
I certainly am not.
We’re talking about guidelines, based on medical resaerch, drawn up by physicans and medical researchers who have no personal or financial stake. . .
This is what Obama has in mind. He has funded comparative effectiveness reserach and has appointed an outstanding panel of physicians and medical experts to oversee it.
We are not being asked to look at the “cost-effectivness” of procedures, just the
“comparative clinical effectiveness” for patients who fit a certain medical profile.
Too often, individual doctors are swayed by the perverse incentives of our fee-for-service system (favoring the most lucrative treatments) and
also have a tendecy to to what they have always done. Today, it is impossible for any single doctor to keep up with all of the research, even in his own specialty.
This is why we need guidelines. Other countires, that use guidelines, have better outcomes than we do.
And in the U.S. multi-specialty centers that use guidelines (including the VA and the Mayo Clinic) have much better outcomes than other sectors of US medicine.
Ben ,
Ben- Grace Jackson’s letter is very good. Thank you. (I urge everone to read it).
But if you look at the panel overseeing this administraton’s comparative effectiveness reserach, you will see that there is no corporate influence that will distort the evidence. The panel members are fine physicians and medical reserachers who have no financial stake in the outcomes– Christine Cassell, a geriatrician and palliative care specialist who is head of the American Board of Internal Medicine, Dr. Jim Weinstein, who is now in charge of the Dartmouth resreach . . . etc. etc.
And they all understand that we are not interested in what works “in principle” but actual outcomes.
Christopher George–
Please see my response to Ben. I doubt you’ve looked at the panel (that you refer to as overlords). They have as much– and probably more– knowledge and experience than 99% of the doctors and medical experts I have met or read –and very little political orthodoxy.
Teo– Apparently you do’t read the newspapers– or medical journals.(I’m surprised that you’re not more familiar with what the administration is talking about because you are a doctor.)
No one is talking about government bureaucrats setting guidelines. The people doing the comparative effectiveness resarch, adn the people anlayzing will be MDs.
Pat S.–
I agree.
Unfortunately, we have a long tradition of “Lone Rangers” (solo practioners) practicing medicine in this country and doing things “my way”–the way they were taught in medical school long ago.
Many dont’ keep up with the literature. I’ll alawys remember seeing a doctor who recommended a particular medication. I happened to have done quite a bit of reserach about it and began to explain why I didn’t want to take it. (Risks outweighing benefits.)
She interrupted me: “I’ve been to medical school and I’m not intersted in continuing my medical education!)
Great,As far as she was concerned,medical progress ended the day she graduated.
This is not patient-centered medicine. It is physician-centered medicine, and as you suggest, ego-driven.
Sorry– the response that begins “Ben” should have
begun: “Ben, Christoper Geroge, Teo and Pat S.
Maggie,
As I mentioned in a previous post, I know a few of the proposed overlords. I am sure they are very smart, but I wouldn’t confuse these with practicing doctors. The woman I know the best is very smart, and has written hundreds of papers. Many of these people come from the New England area where costs are the highest, and results the worst, and the status quo most entrenched. ( So, they can do for the rest of the country what their institutions have done for us here?) They may not have (known) corporate loyalty, but they certainly have a strong bias to send as much money and authority to bloated government supported universities. They will certainly favor the herd clinic over the private office. If you think care is expensive now… Academic practices are the most expensive and least productive.
My objection is to the form, not the personnel. This is really about centralizing the command and control of medicine by the government, by baby steps. Distributed decision makers generally do better then centralized ones.
The real cost drivers are very politically protected or highly desired. (heart disease,back surgery, end of life care, orthopedics ) The legal doctrine of standard of care forces over treatment. There is no defense to the argument that everybody else does x in the event of the occasional (but statistically inevitable) bad outcome.
I think you are mistaken if you think that we need New Men and New Women to enlighten us. We read the same journals that the (according to you and rbar) really smart academics read. Everyone already knows about a lot of the waste, but feel they cannot safely curb it.
I am sure Alan Greenspan is also very smart, but, using his central authority, look at the mess he has made out of the whole country.
The administrative overhead for this sort of scheme is going to be gigantic. Will the unintended and unadvertised intended consequences be worth the huge overhead cost? I don’t know either.
We will have utilization ratings. These will function, as they do in MA, as stealth fee cuts. Doctors will spend their time protecting their “insurance rating”.
I would prefer that they test this method in the really high cost, high litigation states of FL, MA, NY, NJ, PA for a few years and see if it works before they inflict this inchoate concept on the whole country.
We are going to have this. Like many reforms of the past, this will have an expensive bureaucratic life of its own long after the Extra-Ordinary All State Committee has failed to rein in costs.
Christopher–
You couldn’t be more wrong.
The people on the panel are vey famliair with the Dartmouth reserach (on overetreatment and regions of the country that spend more on care.)
And even if they are in the Northeast, they are fighting overtreatment.
You seem to have a blind spot with what you call “academic doctors.”
As Pat has expalined, we do not want thousands of individual doctors making individual decisons.
Outdcomes in the U.S. are worse than in other countries in part because our healthcare system is so fragmented and decentralizied.
Moreover, the doctors on this panel are among the most brilliant in the country.
Half of the doctors out there pacticing medicine graduated in the bottom half of their classes.
I’m sure you know the old joke: What do you call the guy who graduated at the bottom of his med school class? The answer: “doctor.”
Dr. Atul Gawande has written piece about how doctors like electricians, jouranlists and every one else, exist on a Bell Curve.
AT one end, you have a handful of brilliant doctors who practice excellent medicine. AT the other end, you have a handful who are incompetent.
In the broad middle you have the majority of doctors who are, as Gawande acknowledges, “mediocre.”
No, we really don’t want thousands of mediocre phsyicians making independent decisons. We want the folks on the far right-hand edge of the curve draft guidelines for everyone.
Gawande is humble enough to recognize that he needs guidelines (even though he is, almost certainly, one of those on the far-right of the curve.)
With guidelines, we can begin to move the entire curve toward the right,so that “mediocre” will be B+ medicine–not C+ medicine.
If I understand you correctly, you are saying that because our Orwellian Effectiveness Panel has brilliant doctors, they don’t have a political agenda? If that were so, why would they be appointed, and if appointed, why would they serve? The agenda is primary care glorification and decertification of procedures. If that is what the data shows, so much the better.
The panel is primarily non-doctor academics, or non procedural, non practicing academic doctors. (You do understand that generally speaking top half of the medical school class becomes specialists.)
Non-practicing means they have little understanding of why we are behaving the way that we are.
I am all for guidelines. How about competing guidlines? How about diversity of guidelines. Do we really want a one-size fits all guideline? Do we really think that a committee with the power of federal payment regulations behind them will be willing to admit the many mistakes they will make and correct the many unintended consequeces of their actiions? Perhaps you do. I don’t.
Follow guidelines: Good. One size fits all government imposed guidelines: Bad.
When I mentioned Partners, it was only to say that their track record for cost control couldn’t be worse. It may be the most expensive system in the world. So, why don’t we at least start with people from places where costs are currently as reasonable as Europe is now. The University of Minnisota comes to mind.
I have all the respect in the world for academic medicine. I also recognize that it constitutes its own separate interest group. An academic hospital is not just a hospital, but also a think tank for non-practicing doctors supported by the clinical income of the hospital and government grants. That isn’t a special interest?
The doctors are not well paid, but they also don’t do a lot of clinical work either. They write a lot of papers. The result is a very expensive system. Clinical work is looked down on, and the doctors tend to be status-driven rather than money-driven. Neither motive, in my experience, is very reliable.
As individual medical practitioners we do not live on an isolated island nor on a mountain top. We are not truly “solo practitioners”, but, in a metaphysical sense, we are all connected by how we trained, where we trained, how (and why) we continue to see patients and how we continue to keep our medical knowledge up-to-date.
Despite these connections, we are very disparate as persons and as a field of knowledge and practice. In many ways, we are a cottage industry.
Where there are inefficiences and inconsistiencies(and large sums of money are involved), regimentation and commoditization have a potential foothold.
Many are attempting to bring regimentation and commoditization into our the distribution and practice of medical care: Walmart with Intel (http://businessinnovation.cmp.com/articles/res_strat_061211.jhtml?cid=RSSfeed_BI_InfoMgmt); the Agency for Healthcare Research and Quality; CMS; individaul insurance companies, retail urgent care clinics, etc. Each has it’s beliefs regarding the organizational, clinical and financial benefits that could be reaped by (their type of) regimentation and commoditization.
EBM has several roots, but in the end it is one method of coalescing select diseases and presenting each as a national public health issue. Select agencies may use EBMs to give practitoners and the public a sense of certainty as well as a sense of urgency about a disease and treatment.
The concept of “measuring quality” and “benchmarking” have come about in the last 20 or so years in order to soften the talk about cost of care and allocation of (scarce)resources.
So let’s call a spade a spade. EBM, or by any other name, has some honest and more dubious roots. Those who propose to use EBM have overt (and I suspect some subversive) beliefs regarding EBM and plans for the use of this imperfect tool.
As individuals, we refine and continue to use our critical thinking, regardless of what is fed to us (through any source). We may be voices in the wilderness, warning of dogmas and falcious thinking, but it is our duty to remove ourselves only far enough to give us clarity of thought.
Where there is no good data or when there is conflicting EBM information, broad clinical experience still is the best guide for the practice of clinical medicine.
note to Charles and a few others. Good comments that tend to define our differing professional backgrounds.
When you describe physician practice as a cottage industry that not only rings true to many of us, but makes us a bit queasy. We live in a big society with big institutions required to meet standards, whether they are hospitals, insurance companies, drug companies. It doesn’t seem appropriate to have some similar standards for docs beyond the extremely rough justice of med. mal or disciplinary actions. Arguing that medicine is totally different from all other institutions we deal with is an increasingly tough sell.
I’m also a bit troubled by our tendency to ascribe motives. Many, if not most of us, want to do well and do good. So docs want to cure people and live well. Drug firms want products that cure people and yield a profit. Hospitals, too. I’d argue that all of us, including academics, are the prisoners of such mixed motives. where you stand tends to depend on where you sit. but that doesn’t mean a proposition can be automatically deemed as flawed because of where the speaker’s seat is located.
Christopher, Charles, Jim
T.hanks for your comments
Christopher–
AS I have said repeatedly, we are not talking about one-size-fits all guidelines.
We are talking about guidelines for patients who
“fit a particular medical profile.”
As for the panel, I suspect you are lookig at the wrong group. Here is the list: http://www8.nationalacademies.org/cp/CommitteeView.aspx?key=49051
12 of the 16 are MDs, the other four represent consumers or are patient advocates.
I know two of them: Dr. Jim Weinstein (who has practiced for many years and also runs Dartmouth’s shared decision-making program which means he knows far more about practicing patient-centered medicine than most docs) and Dr. Christine Cassell, head of the American Board of INternal Medicine, Cassell is a geriatrician and a palliative care specialist.
Many doctors practicing medicine barely know what palliative care or shared-decision-making (following an international protocol) are.
This is why so many of their patients die in pain, after being tortured by unncessary end of life treatments.
And this is why so many of their patients passively give “infomred consent” to elective surgeries and tests they don’t necesarily need–rather than being able to make an informed choice.
Neither Jim nor Christine is “status-driven” and both are patient-centered, far more concerned bout patients than the vast maority of doctors I encounter in private practice in NYC who so often are money-driven.
Charles–
No one is talking about brining “regimentaion” and “commodificatino” to medicine.
We are talking about bringing science and collaboration to medicine. That means easuring things. Measuing how effective one treatment is when compared to an altnerative treatmenet when used on a very simila patient.
Measuring the value a hospital offers in terms of outcomes and dollars when compared to benchmark hosptials.
Why does Medicare have to spend twice as much at many hospitals than it spends. on very similiar atients, at the Mayo Clnic, where outcomes are better and patient satisfaction and doctor satisfaction higher?
You suggest that doctors practice “teh way they were trained” but the fact is that there is huge regional variation in how
doctors are trained at Harvard, Yale, UCLA, the Mayo Clinic, Kaiser.
A great many doctors are trained to over-treat.
And patents suffer as a restult. (All treatments carry risks; if the treatment is ineffective or unncessary, the patient is exposed to risk without benefit.)
The “wide clinical experience” of any individual doctor is not nearly as valuable as the “wide clinical experience” of a panel of excellent doctors, working together to create guildelines (not rules) that also take into account the ambiguities of medicine and contrary indicators.
As for keeping up with the resarch–we know it takes 8 to 10 years, or more, for very important research to trickle down into medical practice. This means
that many doctors are not keeping up with the research.
This is particuarly true of solo practioners and those who work in very small practices. If you are in a large group practice, “you are much more likely to wind up in a coversation that begins, “Hey did you see that paper . ..” (Here I’m
quoting Christine Cassels, head of the American Board of Internal Medicine.”
Finally, Jim is right, the descriptin of medicine as a “cottage industry” is not reassuring to most paients.
Jim–
You make a good point about standards. And I too am suprised by the evil motives ascribed to academic doctors who are simply trying to do a better job of figuring out what works and what doesn’t.
They really aren’t looking for power; they’re just frusrated because, for years, drug-makers, device-makers and some physicians have fought head-to-head comparisons, knowing that some high-priced treatments that we are using on the majority of patients really aren’t necessary for the majority.
I sincerely hope they do a good job. If this were an easy nut to crack, we might have already solved it. As I have observed in medical practice there are a lot more bad ideas than good one. I hope this group is lucky and finds good ideas.