I found this article at the New York Times on “evidence-based medicine” interesting:
Some of these critics (as well as many readers who comment on my articles) worry that guidelines line the pockets of pharmaceutical companies and radiologists by demanding more drugs and more scans. Others worry that evidence-based medicine makes it harder to get insurance companies to pay for needed care. Insurance companies worry that evidence-based recommendations put them on the hook for treatment with minimal proven value.
Everyone is a bit right here, and everyone is a bit wrong. This battle isn’t new; it has been going on for some time. It’s the old guard versus the new. It’s the patient versus the system. It’s freedom versus rationing. It’s even the individual physician versus the proclamations of a specialized elite.
Because of the tensions in that last conflict, this debate has become somewhat political.
The benefits of evidence-based medicine, when properly applied, are obvious. We can use test characteristics and results to make better diagnoses. We can use evidence from treatments to help people make better choices once diagnoses are made. We can devise research to give us the information we are lacking to improve lives. And, when we have enough studies available, we can look at them together to make widespread recommendations with more confidence than we’d otherwise be able.
When evidence-based medicine is not properly applied, though, it not only undermines its reasons for existence, but it also can lead to harm. Guidelines — and there are many — are often promoted as “evidence-based†even though they rely on “evidence†unsuited to its application. Sometimes, these guidelines are used by vested interests to advance an agenda or control providers.
There are many aspects of the debate. One of them is that physicians are like everybody else. They’re strongly predisposed to do what they’ve been trained to do and, well, 40% of active physicians are over 55. But additionally you can’t be an expert on everything and most physicians’ exposure to probability and statistics is pretty scanty—just enough to get by. That means that most must take someone else’s word for what’s evidence-based and what isn’t.
And physicians tend to resist intrusions by non-physicians into the way they practice rather strongly. I suspect that will be the future of the practice of medicine—fighting a delaying action against non-physicians telling them what to do and trying to preserve the tatters of what’s left of physician autonomy.
Hmm. Don’t think you have it quite right. I think there is a strong element of not wanting to be told what to do. There is also concern about being forced into cookbook medicine. Also, there have been a few times when the guidelines were actually wrong.
That said, I review every bad perioperative outcome in our network. You never see bad outcomes because people were following guidelines. You do see them when people do not. Part of the problem is that too many people want to keep practicing like they did when they first came out. They don’t want to change, and they won’t absent something forcing them to do so. (Isn’t it science that advances by the death of old scientists?) Also, too many docs, I believe, don’t think much about what happens with other health care workers. If you have 5 orthopedic surgeons with 5 different post-op protocols in a hospital, the nurses and PT folks are bound to screw up, or just not be as proficient with each protocol. Following the same protocol, or even just 2 of them, means everyone gets really good at it. And, that care by other people really does count towards a good outcome.
You know that they actually have a rating scale on recommendations made by most medical societies. Much of the time the evidence isn’t especially strong, just “a consensus of expert opinion”.
Steve
(Before the era of guidelines, people believed that mastectomies were the best way to handle breast cancer. There was almost no evidence for that. Folks need to remember that we made mistakes before guidelines were around too.)
The sad fact is that, in Amerika, you have no clues when it comes to finding a good doctor. I screen docs by the words they use: Any doc who says, “at risk for cancer” instead of the proper “at risk of cancer” is immediately written off the list. How else can you pick a doc?
Jimbino, are you saying the appeal of third-world medical care is the proper use of English prepositions?
PD wins today!
Steve