Evidence based medicine at the expense of the art of medicine

Health care in the United States is struggling to redefine itself. We have been spending twice what other countries spend on health care, yet our citizens are less healthy. We now have legislation to create more or less universal insurance coverage, and we are about to embark on a technology-driven quest for quality and uniformity. At the same time, Americans are increasingly turning to alternative health care practitioners, mostly at their own expense, because the health care system is not meeting their needs.

In the three decades since I entered this profession the typical role of physicians has changed dramatically. In the 1980’s most doctors were self-employed and received payment directly from their patients. Now most doctors are employees who receive their salaries from organizations that collect payment from insurance companies on behalf of the patients.

With this arrangement patients have lost the power that came with directly paying doctors for their services. Doctors now have to answer not only to their patients, but also to their own employers and to the insurance companies, whose profits are carved from the difference between insurance premiums collected and medical care delivered.

Medicine has until now been considered one of the three learned professions along with Law and Theology. These three professions are said to require advanced learning and high principles. Physicians, lawyers and clergy study and interpret their material. They sometimes find themselves in a position where they are forced to disagree with others of similar training, who draw different conclusions from the same text.

It is very tempting to think that there is only one right way to do things in medicine. After all, medicine is a science, and we spend a lot of money on doctors, tests and treatments. For those who remember, Marxism was also touted as a science, yet the planned economies of the world collapsed because their scientific theory created systems that were too large and rigid to manage effectively, let alone meet the needs of their customers.

Every day I read about medical errors that only computers could avoid and alleged epidemics of unprofessional conduct, negligence and incompetence among physicians. The solution is made to seem obvious: change the role of physicians from intellectually independent professionals to generic health care providers. Put them in front of computers that offer “Decision Support,” which is jargon for suggesting to them what to do, and then measure their compliance with the computer’s suggestions.

Even the New England Journal of Medicine recently printed an article that suggested that computers could make unnecessary the “master diagnosticians of past eras.”

Is it any wonder that so many hard-working, decent doctors are dissatisfied with their careers? Is it any wonder that the primary care specialties are having recruitment problems?

Doctors will happily do the right thing, if we show them what the right thing is, President Obama inferred after the United States Public Health Service recommended cutting back on mammography screenings.

This is an example of where we, unfortunately, stand with “Evidence-Based Medicine” (EBM) in the United States today. The mammography recommendations were changed, not because the evidence changed, but because the task force looked at the data differently.

“Evidence Based Medicine,” in my opinion, requires individual physicians to continue to act as professionals, read the literature and expert opinions with a discerning eye, look for bias and ultimately help individual patients with unique situations take the best action.

The proponents of uniformity, today’s capitalists or yesterday’s Marxists, have both failed to understand the art in what we do. Health care is like food, wine or music. The ingredients, even the recipes, may look similar, but the interpretation and delivery makes it what it is. Two different doctors can deliver the same care in theory but get different clinical results and different patient satisfaction. And two patients with the same stage of a disease may respond differently to the same treatment.

In 1996 Nobel Prize winner Bernard Lown wrote The Lost Art of Healing. It is still missing in many places.

No matter how technologically advanced medicine gets, and no matter what financial or administrative pressures doctors are subjected to, ours is a healing profession. Our duty is to maintain our professionalism and use our scientific training, never forgetting that patients come to us to be healed or comforted. Even our Evidence-Based treatments are sometimes only marginally better than placebo, for example antidepressants. A therapeutic relationship between doctor and patient can sometimes do more for a patient’s health than a hastily delivered, computer-generated prescription.

Physicians need to take pride in their work and act like doctors, not health care drones, who blindly and mindlessly toil for the big health care machine.

A Country Doctor is a family physician who blogs at A Country Doctor Writes:.

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  • http://bittersweetmedicine.com DrLemmon

    Evidence based medicine, comparative effectiveness research and expert guidelines are great tools. I study them and employ them because they help me practice better medicine.

    However, the problem is these guides end up getting treated like rules. Since exceptions are so common in medicine applying these tools rigidly actually worsens care for many patients. But if you deviate from the approved course you risk being labeled a second tier or “low quality” physician.

    It is good that A Country Doctor spoke out for us and our patients.

  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    This is an excellent post, which will be read by those who don’t need to read it.

  • http://www.brokenmarionettebook.com Maija Haavisto

    Sadly, a lot of “evidence based medicine” is thoroughly flawed and not based on any real evidence (I’m not talking about the mammography recommendations; the science seems to be very sound). But a lot of doctors just don’t understand it, they treat everything labeled as EBM as undisputable fact, often with tragic results. E.g. one of the “EBM” treatment recommendations for one of the most common neurological diseases is completely unhelpful and worse, extremely dangerous to the point of being life-threatening.

  • Doc99

    “Medicine is an art based on science.”
    Sir William Osler

    If we overemphasize the science, we will lose the art.

  • http://www.cyberdentist.blogspot.com Dean

    “Evidence” based medicine will be used to deny coverage for certain kinds of procedures or treatments. Anyone who actually practices medicine (or dentistry) knows patient treatment is a blend of art and science. A filling is not a filling is not a filling. There is a person there. By the way, “evidence” is not only cold science (which is important), but also information gained from talking to patients and long term experience of what really “works” or does not.

  • William Hsu

    Evidense based medicine may not provide all the answers needed in medicine, but it provides the best answers available.
    Medicine is vast and there are several areas where the best treatment is unclear, this is where the art of medicine can come into play. But when doctors practice medicine that stands in opposed to clearly benificial treatments based of evidense based medicine, I cringe. There are doctors out there who don’t vaccinate children, distribute antibiotics to clearly viral infections, inappropriately order/neglect diagnostic imagining/blood test.
    Doctors are people and as such they can put too much importance on “personal experience” and too little importance on actual clinical trials- this can be dangerous. Doctors who support the anti vaccine movement, like dr. jay gordon, are prime examples where doctors who trust thier own “experience” can be dangerous.
    Uniformity isn’t bad when it’s correct. Automobiles are safer because they all have seat belts, air travel is safer because pilots follow checklists, surgical infection rates are low because the OR staff follows strict washing guidelines. Medicine is a feild that can benifit from a certain level of uniformity. The key is finding the right level of unifomity.

    • Doc99

      Dr. Hsu … History has demonstrated that medicine swings like a pendulum do. And a randomized controlled trial often begins with but a single anecdote. EBM may be a starting point but it is not nor should it be regarded as ex cathedra.

      • William Hsu

        First off, I want to say I’m a med student, I’m not a doctor yet. I don’t want to misrepresent myself.

        With that being said, medicine is both art and science. I never said medicine was “ex cathedra”. In fact in the first sentence of my post I mentioned that EBM was limited.

        While it is true there are pendulum swings in medicine, it’s also true there are “medical steps” as well- pivotal points in time where NOT adapting certain practices will mean a lower quality of care. The introduction of hand washing, vaccines, anesthesia, antibiotics would be the most obviuos examples of medical steps.

        Uniformity in medicine is needed to ensure that the minimal level of care is still high level medical care. EBM should direct what constitutes minimal standard of care. But in areas where the evidense is unclear, the art of medicine can come into play.

        EBM isn’t the starting point of medicine, it is the foundation. Essentially all treatments of disease were based of some sort of clinical review or scientific understanding about a disease. All medical textbooks and medical resources comes with an extensive bibliographies of various clinical studies. Evidense is what separates doctors from chiropractors, acuputurists, herbal healers and all other people who practice “alternative medicine”. Medicine strives to go beyond anecdotal.

  • William Hsu

    I often like this analogy when explain the balance between art and science of medicine.

    Medicine is like poker. EBM tells you the odds of winning based off your hand. The art of medicine dictates how you use those odds in your style of play (aggresive, conservative, etc).

    Always remember, reguardless of the odds and style of play, you’re going to lose some hands.

    • http://www.yourcaringtherapist.com Jay E. Korman

      “Evidenced Based Treatment” is also foisted on psychotherapists and, in some ways, turns both the art and science of psychotherapy into a “cookie cutter” approach that says for this diagnosis do these things. All well and good but the diagnosis isn’t sitting in the consulting room with us, just the same as the diagnosis isn’t sitting in the examining room with you.

      There has always been “evidence based” treatment, even if it hasn’t been called that. As new evidence comes to light new treatments can be considered. Unfortunately mental illness isn’t as simple as physical illness (not that that’s “simple,” it’s just that the symptoms aren’t as easy to pin down to a source with a differential diagnosis as in physical medicine) and what works for one patient, based on analysis of the symptoms, may not work for another.

      This still doesn’t mean the treatment isn’t based on evidence. It may mean that we don’t have enough evidence to narrow the causes of mental distress down to a few that can be treated with a pill or a few treatment regimens. It may also mean that, at least in the mental health field, we’ve spent too much time sub-dividing the types of suffering and giving each a label. It also means that the payers are able to partially dictate treatment by determining what they will and won’t pay based on the use (or not) of “evidence based treatment.” This means that what a competent clinician determines is the best course of treatment for his/her patient is second guessed by the very company that is supposed to be insuring that the patient gets the treatment he/she needs at a “reasonable” price (but is it really reasonable.)

      Doctors, lawyers and theologists aren’t the only professionals who go through extensive postgraduate training and training and training. Clinical social workers aren’t a “3rd tier,” as I’ve seen it expressed, and are dedicated (and very capable) clinicians who take their profession seriously and their patients as people in need of assistance. The evidence we go on is, as stated in another comment, what we see presented to us in the consulting room on an ongoing basis and subject to continuous evaluation and re-evaluation.

      The pendulum will swing and at some point it will be accepted again that we are all professionals and our judgement in how to treat our patients will count for more than what the statisticians determine to be the best treatment based on evidence gained by the treatment of other patients.

  • bw

    I’m a third year medical student, and I can’t tell you how hard they try to push Evidence-Based Medicine at us in school. It is not that I am against medicine practiced based on evidence, but the concept of using data from other patients (that are not our patient, and may not even be similar to our patient) to guide our decisions only brings an inappropriate uniformity and standardization to the practice of medicine. Unfortunately, like most things in our country, standardization, in this sense, brings quality care down, just as it brings the lower end up, with a result at a somewhat lower average than before. Just look at the standardization of the school system.

    I like what Sappira writes, “…the sine qua non of science is not a multimillion-dollar RCT, but an honest, objective, reproducible observation; a critical attitude; constant hypothesis testing; and a desire to seek and correct errors.” He also quotes Hampton, “The strict application of EBM implies a computerlike approach in which the doctor sees the patient as a statistic rather than an individual. This sort of medicine could be practiced by administrators. In the real world, however, clinical trials may tell which treatments are effective, but not necessarily which patients should receive them.”

    • Blacktag

      Maybe you’re right, and that standardization is bringing down the average. It explains why American physicians are disagreeing with the task force recommendations to reduce frequency of screening mammography. And I thought it was sad enough that politicians see the opportunity to score points by exploiting the ignorance of the public.

      William Hsu had it right – if you don’t know the odds in a poker game, the odds are that you’re going to play a little worse. I don’t know just how many people actually could quote offhand the benefit of screening mammography. So if you’re a medical student, try to get to know those odds a little better with a good dose of epidemiology.

      The art of medicine is truly customizing those odds for the individual. But I bet no one is going to tell you that.

      • Doc99

        You still have to “Know when to Hold ‘em … and Know when to fold ‘em.” EBM may get you to the table but the Art of Poker will get you the Bracelet.

        Once you med students find yourself dealing with that patient who “hasn’t read the book,” then the learning process will begin in earnest.

  • http://bittersweetmedicine.com/ Dr Lemmon

    BW, that was an excellent reply. I think you will become a fine physician. I’d bet you have talent.

  • Reality

    Wonderful post. I’m afraid the political and special powers that be are pushing cookbook medicine to further their control over the health care system. There is nothing wrong about using evidence and guidelines (I’m a physician-scientist) but when you start enforcing guidelines, you can run into dangerous situations if the enforcement robs the physician of their autonomy to make decisions and use their clinical judgement.

    At the end of the day, this debate is part of a larger paradigm which is not about health per se, but control and the mighty dollar.

    • Anonymous

      The unfortunate part is that this ‘cookbook medicine’ is what will be used by malpractice attorneys during lawsuits. As stated above, this removes the autonomy from any medical decision and places the physician at greater risk for any medical decision that goes against the standard of care (which will be based on these protocols).

  • http://www.musclerepairshop.com Butch Phelps

    Corporations love one size fits all, they can mass produce it. If they can get doctors to agree with them, then they can have more clout to sell patients the idea. As you well knwo, no 2 patients are the same. I know you are correct and I can only hope doctors can go back to healing.

  • http://somebodyhealme.dianalee.net Diana Lee

    Great article. As a patient the emphasis on evidence-based medicine has left me feeling like a failure when none of the approaches supported by the evidence have helped me.

  • Doc99

    Remember, often a metanalysis is nothing more than the statistical equivalent of trying to make a silk purse out of a sow’s ear.

  • http://www.comsi.com JeffBrandt

    Great conversation, As a Medical Informatics Grad student I get to view the bleeding edge of the discussion. EDM, CDS, CPOE have been developed to assist the provider in their job, not to replace. But in saying this, replacement is certain situations is going to happen. Robotic surgery is here and the outcomes are good. There is a shortage of PCP and CPOE and CDS systems can assist Nurse Practitioners and PA to fill these gaps.

    The article mentions that most docs today get a paycheck now instead of working for themselves. Well. that is the nature of most businesses, It has become too expensive for most businesses in the USA to support themselves. That is why Wallmart replaced the vacuum and TV appliance sort of the 60′s. We may not like it but….

    Change will happen and all we can really do it try to help in building better systems and provide direction. Many docs are becoming students in the field of Medical Informatics, so there are many out there that believe that these systems have possiblities. We need providers constructive input to build better systems. I think we all see the future of medicine, we can either embrace and be part of the control and direction or let “it” control us.

    We are all patients,

    Jeff Brandt

  • Mary Andrawis

    Dear Mr. Country Doctor and commenters,

    I read this post and the subsequent discussion with fascination. Just this week I gave a presentation on the topic of evidence based medicine, and presented a study that identified this notion of guidelines being “too cookbook” as a major barrier to implementation of guidelines. I was so moved that I blogged a few main points from my perspective. I’m very interested in hearing what all of you have to say, so read on: http://ashpblog.squarespace.com/blog/2010/6/17/the-two-headed-beast-the-art-versus-science-of-medicine.html

    …thanks for a thought provoking post, Country Doc.