October 20, 2009
BehindTheMedspeak: The dirty little secret of evidence-based medicine
Norbert Gleicher's Op-Ed page piece in yesterday's Wall Street Journal succinctly undressed the erstwhile new belle of the health care reform ball, namely "evidence-based" medicine, which purports to create best-practice scenarios based on the results of published reports as opposed to old-fashioned physician experience and judgment.
Long story short: "Studies published in the medical literature are mostly produced by academics who face an imperative to publish or watch their careers perish. These academics aren't basing their careers on their clinical skills and experiences. Paradoxically, if we allow the academic literature to set guidelines for accepted practices, we are allowing those who are often academics first and clinicians second to determine what clinical care is appropriate."
The essay follows.
Expert Panels Won't Improve Health Care
At a town-hall meeting in New Hampshire this summer, President Barack Obama explained why government "expert panels" are an essential part to overhauling the health-care system. Right now the United States spends $6,000 more per person each year than other advanced nations and isn't healthier for it. He said these panels would reduce wasteful spending by providing "guidelines" for doctors on which procedures to perform.
His panels are now part of legislation moving in Congress. But the idea of inserting a government panel between patients and physicians remains contentious and with good reason. Inevitably, the panels' guidelines will come to be seen as the industry's "best practices" and would therefore be adopted as a blueprint for which procedures health insurance should cover.
The idea of creating expert panels has a certain logic to it. After all, who is better qualified to determine best medical practices than medical experts? The medical field itself has been edging toward a similar approach in recent years with "evidence based medicine," an approach that assumes it is possible to determine what works and what doesn't by reviewing published medical literature.
Evidence-based medicine has some value, but it can provide misleading information. Determining which studies to review, for example, can introduce biases. Whether investigators accept published data at face value or repeat primary data analyses also matters. If the data in a published study were poorly analyzed or, for argument's sake, completely invented, relying on it can lead to faulty conclusions. It's an unfortunate reality, but our medical literature is significantly contaminated by poorly conducted studies, inappropriate statistical methodologies, and sometimes scientific fraud.
Of course evidence-based data can be useful. But I have seen firsthand how it can be dangerous.
Several years ago I grew concerned about my postmenopausal mother's risk of osteoporosis. I tried to convince her to initiate hormone replacement therapy. She didn't listen to me. Instead, she spoke with her gynecologist, who—contrary to best medical evidence at the time—recommended against such treatment. I would eventually be thankful my mother listened to the gynecologist who had known her for decades instead of me and the published medical reviews I was relying on. Some years later my mother was diagnosed with early breast cancer. Had she been on estrogen replacement, it is likely that her tumor would have progressed more rapidly. The gynecologist likely saved my mother's life.
Studies published in the medical literature are mostly produced by academics who face an imperative to publish or watch their careers perish. These academics aren't basing their careers on their clinical skills and experiences. Paradoxically, if we allow the academic literature to set guidelines for accepted practices, we are allowing those who are often academics first and clinicians second to determine what clinical care is appropriate.
Consciously or not, those who provide the peer review for medical journals are influenced by whether the work they are reviewing will impact their standing in the medical community. This is a dilemma. The experts who serve as reviewers compete with the work they are reviewing. Leaders in every community, therefore, exert disproportional influence on what gets published. We expect reviewers to be objective and free of conflicts, but in truth, only rarely is that the case.
Albert Einstein once noted that "a foolish faith in authority is the worst enemy of truth." At the moment, there isn't an overreliance on expert panels in health care. Our system can therefore self-correct when experts lead us astray. This has given us the best medical care in the world, which is still envied by people from all over the world who face much more rigid, government-driven health care.
This does not mean that our system should not be improved. It is far from perfect. The country needs universal health-care coverage, must do away with exclusions for pre-existing conditions, and must make insurance a portable benefit. But expert panels would only slow medical progress and delay rejection of false prophecies and dogmas. These panels would interrupt a well working free market of ideas in health care, where effective therapies can rise to the surface and win out.
What is it?
Apple rocks my world
Gaze in rapt admiration and awe at my next computer, just announced by Apple and already on its way to bookofjoe World Headquarters™ here in Charlottesville.
As is so often the case with my second-favorite company (Google's #1), they've exceeded expectations with that stupendous, eye-wateringly beautiful 27" screen.
Did I mention that I've been creating bookofjoe on my 15" G4 PowerBook (currently running 10.3.9) since the spring of 2005?
I'm barely able to stay on the treadmill as I type these words, I'm so excited.
From the website:
Tape-2-USB Recorder — No Conversion Service Needed
The advent of the CD resulted in much of our favorite music collecting dust on obsolete cassettes. Get out those cassettes and introduce them to the latest in technology.
The Tape-2-USB recorder is a fully functional cassette deck with USB plug-and-play interface — no drivers required.
Your cassette tracks can be uploaded to PC or MAC, burned to CD-R or CD-RW, or transferred to your MP3 library.
Built-in speakers allow for easy monitoring of your music while recording it to your computer.
Includes software for audio enhancement editing, USB cables, UL®-listed AC adapter, and complete instructions.
10" x 6" x 3".
Helpful Hints from joeeze: Drano works — you just have to be persistent
Or, to put it another way: if at first you don't succeed in clearing the drain, pour in another half container.
And yet another.
And one more... wait... what's that giant sucking sound?
Notwithstanding my excellent plumber Kevin Burns's admonition not to use Liquid Plumber and its ilk because it's bad for your pipes, I must say that last Saturday morning when for no apparent reason my kitchen sink stopped draining, I wasn't in any mood to wait till Monday to ring up Kevin to make a house call ($75 just to knock on my door) when I had six bottles of Drano Gel sitting there on the laundry room shelf.
It's a lot cheaper, faster and more satisfying doing it yourself.
Don't worry, Kevin, there's plenty of other stuff just waiting to go on the fritz that's not amenable to my TechnoDolt™ approach.
Harley-Davidson Wind-Up LED Flashlight — Old school meets new
Bug of the Week
Every week Michael J. Raupp, professor of entomology at the University of Maryland, offers a multimedia extravaganza featuring one denizen of the insect world.
Eames x Bokja
£5,500 at their flagship store in Saifi Village (Building 332, Mukhailassya Street, Beirut).