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October 20, 2009

BehindTheMedspeak: The dirty little secret of evidence-based medicine

Doctor -- patient - relationship

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.

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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.

October 20, 2009 at 04:01 PM | Permalink


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Comments

Here's a little game, boys and girls:

Can you spot the 0bama voter in this thread?

Posted by: Rob De Witt | Nov 4, 2009 7:38:53 PM

Wow, this author's disdain for evidence-based reasoning is illustrating by his unfounded assertions and single anecdote to indict an entire field. Had his mother broken her hip and died of complications, he would conclude that evidence-based medicine is perfect. Luck is not adequate for epidemiological levels of care. Even his conclusion is illogical. In his opening, he states that despite spending more than any country on earth for our care, we achieve worse outcomes than other advanced nations; he then concludes that we have the best care in the world. I suppose if you do not believe in objectivity then you do not have to worry about the ridiculousness of such a statement. Way to add to the debate.

Posted by: bob | Oct 21, 2009 6:22:23 PM

A bit of snark: if we relied on expert panels and did not allow outlier opinion, our computers (if they existed at all) would be re-calculating the epicycles of how everything revolves around the Earth.

OK, generally stick with the exerts - but "in general" is NOT "always."

Posted by: John A | Oct 20, 2009 6:49:14 PM

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