Patients often reject evidence based medicine

A recent study from Health Affairs found that people are skeptical about evidence-based care.

I’ll admit, my first reaction was, “they needed a study for that?”

Regular readers of this blog know that I think patients need to share the responsibility with doctors when it comes to embracing evidence-based medicine.

According to the study,

… participants also believed that any new treatment is improved treatment. This attitude may help explain the survey finding that only 47 percent of respondents agreed that it is reasonable to pay less out of pocket for the most effective treatments and drugs. Linking cost sharing to clinical effectiveness may be perceived as restricting treatment options, particularly for unproven therapies.

This corroborates conventional public wisdom that more care is better medicine — which is not always to case. The concepts of false positives and complications stemming from increasingly invasive studies ring hollow to most.

Health reformers who advocate using evidence and comparative effectiveness studies to control costs and reduce waste are going to meet a resistant consumer:

Given the widespread view that lower-cost care is clinically inferior, it is perhaps not surprising that focus-group participants found it inappropriate to discuss with their physician the costs of different treatments, believing that decisions about medical treatments should be based on individual needs alone. A number of participants reacted negatively to the term “good value for the money,” equating it with bargain-basement pricing and low quality.

The proposed solution, of course, is to better educate patients. But given how entrenched these beliefs are, it’s going to be a long, slow process.

Hopefully the Health Affairs piece will force health reformers to acknowledge that patients themselves need to play a shared role in accepting evidence-based medical decisions, instead of placing the responsibility solely at the feet of doctors.

Otherwise, all the comparative effectiveness data in the world will only fall upon deaf ears.

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  • BettyB

    I keep receiving soliticiation for mammography from one a prominent hospital. The last one interviewed on of their radiologists, who proceeded to explain why the evidence used by the USPSTF was wrong. I also received a letter from this same hospital that digital mammography was superior to film at a time when there were no studies to show this. Digital mammography was more expensive.

    When I tell my doctor that I do not wish to participate in screening mammography, I am told that I am making a big mistake. So much for evidence based medicine.

  • rezmed09

    Evidence based medicine is only as good as the latest study. Estrogens are now out. Vioxx is now out. A1C’s don’t have to be 6.5. Alendronate actually may be bad for your bones. Digoxin is in, out, in (maybe). Maybe breast self exam is useless, and mammograms are overused.
    I can see why evidence-based information is not trusted – it changes as do our recommendations.

    But the elephant in the room is direct to consumer drug advertising. Not only It is hard for scientific evidence to be sifted through when we have corporate sponsors of studies and investigators, it is even harder for the data to be balanced against drug advertisements. Now it is the job of a doc to look at the data, stay up to date, and then counter the onslaught of drug requests from patients, who want the “that pill”. We frequently forget the power of advertising – it works even though we think it does.

  • A. N. Mous

    Yes, the ACR and directors of “Breast Centers” all over the nation united in one voice to denounce the latest recommendations on mammography. They tried to hide behind concern for the patient – but the real reason was concern for their profits.

  • Trisha Torrey

    With all due respect, Kevin, and coming from the perspective of the patient, I believe Health Affairs has missed the boat on this one in an entirely different way.

    With the exception of some of us emPatients (empowered patients), you won’t find many of us participating meaningfully in our care decisions until the entire profit system of American healthcare is shifted.

    As an example: just who is going to teach patients to understand evidence based medicine? Do you teach it to your patients? Do you have time? And suppose they begin to understand it – who’s going to discuss the evidence with them, the pros and cons of any given treatment need? Even then, suppose they understand it, and make a different choice from what you believe is the better choice? Do you risk being sued if they make a different choice, you carry it out, and it fails?

    There are a dozen other examples of why this wholesale recommendation that patients take an active role can’t work with the current system…. but the bottom line is this: we patients WANT to participate. We WANT to understand. But there’s no one to partner with to do it right as long as our time with our providers is so short, and as long as pharma is working so hard to manipulate our care.

    For now, just like Health Affairs did, it’s far easier to blame the patient than work toward policy changes… so this is just one more dun on us patients – the invisible stakeholders in healthcare.

    Here’s more about the same study, with additional examples.

    Trisha Torrey
    Every Patient’s Advocate

    • Kevin

      Thanks for your reply Trisha.

      I was careful to word my response so that the blame isn’t all on the doctors or patients.

      Like shared medical decision making, both doctors and patients need to take responsibility when confronted with comparative effectiveness data that challenges conventional wisdom. Without both stakeholders, there’s little hope of changing the “more is better” mentality.

      Regarding your other points, I agree wholeheartedly. Keep an eye out on in the next week or so, where I authored a piece addressing those very issues you raised.


      • MB

        I would also add that the average person does not have experience in statistical analysis-I would guess a large number struggled through basic algebra.

        From Scientific American-April 2009:
        …only about one out of every 10 women who test positive in screening actually has breast cancer. The other nine are falsely alarmed. Prior to training, most (60 percent) of the gynecologists answered 90 percent or 81 percent [chance that the woman actually has cancer], thus grossly overestimating the probability of cancer. Only 21 percent of physicians picked the best answer—one out of 10.

        So if doctors have trouble with statistics and the patient has difficulty with basic mathematical ideas, how can a patient make an informed decision. I once ask my doctor for the negative predictive value of a blood test she had run. She didn’t know.

  • PatMatRat

    Rezmed should refer to Asimov’s The Relativity of Wrong. A1C does not have to be 6.5? I call bullshit. Studies showed that below 7, the risks may outweigh the benefits but does that mean that we were wrong to say 6.5? Not at all.

    Evidence-based medicine refines our knowledge. You seem to suggest it’s completely random suggestions based on a whim. It’s called “evidence” for a reason – there was evidence for whatever conclusion in the past, but that knowledge was refined and so was the conclusion.

  • Hilary

    I have great caution about evidence based medicine. I love the idea in theory but in practice EBM is used to push the latest drug. Very few people are educated enough or have enough concern to pick apart research papers as most of them are written by people with a vested interest – if they aren’t paid by the drug companies most are paid by institutions which have a vested interest in being well regarded by the drug companies.
    As a patient I have been given recommendations direct from the drug companies via their mouthpiece the local doctor. When I asked for the research, if the doctor wasn’t so upset by the idea of giving it to me, then I found that the research didn’t say what the doctor said it said.
    I have read hundreds of medical papers over the years – a great many have results which are different to the discussions which may be different to the abstract and the title. There are cases where the research was set up to prove that a drug worked with a method to match, not find out whether it did. One example was when deaths during treatment were deleted from the results in order to make sure that the long term survival rates were better than they were.
    Let’s face it, researchers and medical practitioners are trained by and have to be accountable to their colleagues, many of whom only read the abstracts of papers, if that. Medicine is taught by custom, not by EBM and EBM, I suggest, in the vast majority of cases isn’t very evidence based because of vested interests. I no longer believe anything unless I read the evidence myself and take apart their methods to see if and where they are fudging it.

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