Health care needs public acceptance of evidence based medicine

Although a majority of Americans probably couldn’t give you an accurate description of the differences between fascism, socialism, and communism, they have no trouble applying–and often interchanging–those labels to any effort by government to reform health care.

And, based on their efforts, one might conclude that the defining characteristic of any government involvement in health care is rationing. As if we don’t already ration, but will as soon as the government intrudes.

Now that isn’t to say that there aren’t some legitimate concerns involved in expanding access to health care in this country, because there are. For instance, we already have areas in this country with a shortage of physicians, and when uninsured people are suddenly insured, their demand for services will be actualized and the physician shortage will be exacerbated. Some people take that to mean that they won’t be able to see a doctor without bread line depression-era style waits.

I don’t think that’s remotely close to what will actually happen, but even if it did, there would be a simple fix: produce more doctors in this country. Plenty of smart, talented people are denied admission to U.S. medical schools every year. I honestly do not think that the quality of U.S. medical care would suffer by extending enrollment at the margins.

Then there’s the issue of rationing that people fear will go on at the doctor’s office. They worry that in a governmental effort to “pinch pennies” patients won’t be able to get the best care like they supposedly can now. There’s a tremendous amount of concern about the idea of evidence-based medicine. Apparently people don’t trust the name–or else they prefer their treatments to be based on something other than evidence. An article just published in Health Affairs gets to the root of these fears.

The study’s authors basically find that people don’t know what evidence-based medicine really means, don’t tend to get involved in decision making about their health care (preferring their physicians to make the decisions), and continue to hold on strongly to the belief that more care–and more expensive care–is always better. You would think that an entire nation of people raised up on the fairytale of Goldilocks and the Three Bears would realize that extremes in either direction aren’t usually the best course of action.

Still, the authors found that people translate the phrase evidence-based medicine to mean that the government steps in and tells doctors how they have to practice by establishing evidence-based guidelines that can’t be overridden or changed in any way. That view, unfortunately, is just plain wrong, and explains how the public’s misconceptions remain one of the greatest barriers to improving our health care system.

Brad Wright is a health policy doctoral student who blogs at Wright on Health.

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  • http://www.twitter.com/alicearobertson Alice

    You would think that an entire nation of people raised up on the fairytale of Goldilocks and the Three Bears would realize that extremes in either direction aren’t usually the best course of action.
    [end quote]

    I can concur with some of your deductions, but I am on the other extreme and tend to think our educational system is a type of assembly line that doesn’t teach real thinking skills. Why do I bring this up? I bring it up because it’s the only conclusion I can come to for some of the data that is either believed on a surface level, or for why some people think emotionally and not with logic. It’s not really about intelligence, but deciphering, sorting out of fallacy (which is becoming abundantly hard), and sometimes just common sense.

    Apparently, if we can make the word “totalitarianism” less potent, stamp governmental forms of socialism as labels of the misinformed, or claim that those against the health care bill just don’t get it…it justifies it. Basically, if I disagree with the study in Health Affairs I have been reading too many fairy tales? Maybe it just depends on what version of those tales we have been reading.

  • Thomas Reid MD PhD FACP

    Mr Wright is incorrect in stating that government guidelines aren’t similar to telling doctors what to do. Such guidelines can be used by insurers to disallow coverage. Take, for example, the USPSTF guidelines on virtual colonoscopy for Medicare recipients. They argued that the potential increased cost of working up incidental findings would not make virtual colonoscopy cost effective. Hogwash. Nevertheless, Medicare is using these guidelines.
    For women, it was fortunate that they and their physicians created a firestorm against the USPSTF mammogram recommendations. Otherwise, Medicare/Medicaid and insurance companies would have followed these as well.
    Guidelines must be left to the subspecialty medical societies who do an excellent job already at comparative effectiveness research. When the government gets involved, comparative effectiveness equals rationing based on a poor thought process.

  • paul

    acceptance and successful widespread implementation of evidence-based medicine or comparative effectiveness research or whatever you want to call it requires our society as a whole coming to terms with some defined miss rate that we deem acceptable.

    medicine in its purist form is an art, because every single patient is a unique individual that, in an ideal world with infinite resources, needs tailored care to meet their individual needs. if you apply the results of some large well-designed RCT to a population you will probably get the most cost-effective health care and may even overall get better outcomes, but every now and then you will encounter an outlier for whom the algorithm won’t apply and will consequently suffer a bad outcome. the question we as a society need to answer is, what miss rate is acceptable?

    say, for a life threatening diagnosis, that a certain number of a given list of symptoms/findings is required to prompt a certain diagnostic test. if this strategy misses the diagnosis once every 10,000 times in patients for whom the test is not ordered according to the algorithm, is that acceptable? how about 1 in a million? the benefits are that strict application of these algorithms is cost-effective, reduces unnecessary variations in clinical practice, and may help to minimize human error. the drawbacks are that it reduces NECESSARY variations in clinical practice (in other words, compromises the art of medicine) and patients who want some test even if they fall out of the algorithm can’t have it (unless there’s some built in mechanism to have them pay for it out of pocket). unfortunately, we seem to be headed in a direction where these algorithms are enforced with payment decisions- for example, you cannot be compensated for performing test X if the patient doesn’t qualify according to the list of symptoms/findings. now, if we as a society have decided that we must do things that way because of the cost problem and have all agreed upon some defined acceptable miss rate, that’s fine. what concerns me is that these CER guidelines, once implemented, will probably come with the disclaimer that, even though the individual provider’s financial viability may depend on following the guidelines, at the end of the day they are just guidelines and if you fail to recognize the patient in front of you as being an outlier for whom the guidelines won’t work… well, it’s your fault for not recognizing it (thereby giving the enforcers of the guidelines immunity from liability). as long as that loophole remains in place, i foresee providers continuing to do what they can to protect themselves (or get patients what they need, depending on how you look at things), and health care costs continuing to spiral out of control.

    oh, and maybe i should have prefaced all of this by reminding everyone that there is no such thing as a zero miss rate no matter how medicine is practiced, but i figured that should go without saying.

  • http://www.twitter.com/alicearobertson Alice

    oh, and maybe i should have prefaced all of this by reminding everyone that there is no such thing as a zero miss rate no matter how medicine is practiced, but i figured that should go without saying. [end quote]

    Mistakes are a given, but how they are handled makes a world of difference, and prevention is utmost.

    The topic of the Michael Medved show was malpractice. A malpractice attorney and an author/attorney Philip Howard (who wrote The Death of Common Sense, and is working with Harvard medical about the issues discussed here) discussed this. Discussing why a panel of a variety of individuals would be better than a jury where you can get different decisions, and if a person loses their case they can end up on disability via the government, etc. I believe they said there are mistakes in close to 25% of ER visits? I wish I had the transcript, but obviously, some mistakes are overcome and the patient doesn’t know about them, while others (they discussed the problem of a cheap CT scan compared to an MRI that can discover a herniated disc and some people end up partially paralysed from lack of a diagnosis).

    Some good ideas are on the table, but sometimes it seems doctors are the most resistant to change (and admission of errors). And like capitalism when the hospitals, doctors, and insurance companies mess up the government jumps to the rescue, and sometimes it seems they help a few and hurt a lot. In truth, I think a small segment of doctors have caused a huge mess for patients and other doctors.

    • HJ

      RE: zero miss rate

      This isn’t about mistakes, it’s about the specificity and the sensitivity of a particular test.

      Suppose you had a test for a condition that had a 95% sensitivity and a 90% specificity. That means that 5% of those who test positive aren’t sick and 15% of those that test negative are sick.

      Positive predictive value is the probability that one has the condition given that one tested positive. For the % above, the positive predictive value is 51.4% while the negative predictive value, the probability that one is heathly given that one tested negative, is 99.4%.

      So almost of those receiving a positive test don’t really have the condition. Is it worthwhile? What about the 0.6% that are sick but failed to get a diagnosis? So the question is how well a certain test helps pinpoint a diagnosis and who should decide that test is worthwhile.

  • paul

    i don’t disagree with you that physicians need to be reformed. i don’t even think that will be a big problem, considering how politically impotent they are as a group and how successfully they’ve been publicly vilified during the whole process of health care reform. the problem is that really every entity involved in health care needs to be reformed and yet every entity involved believes that they are the one group that is doing nothing wrong and does not need to change. i’ve heard that physician pay accounts for 10% of health care spending. if that number is correct, you could make all doctors work for free and we’ll only cut health care spending by 10%. i think we need to do better than that.

    anyway, we can throw out statistics all day to push our own agenda- two trial lawyers claiming that one out of 4 ER patients are the victim of a physician error? you would think america would be an empty ghost town by now, between that and the IOM report that 100,000 people die every year from medical mistakes. patients are dropping like flies! by the way, did you know that one out of 2 lawyers whose case goes to trial screws up and loses their case?

  • http://www.twitter.com/alicearobertson Alice

    anyway, we can throw out statistics all day to push our own agenda- two trial lawyers
    claiming that one out of 4 ER patients are the victim of a physician error? you would
    think america would be an empty ghost town by now, between that and the IOM report that 100,000 people die every year from medical mistakes. patients are dropping like flies! by the way, did you know that one out of 2 lawyers whose case goes to trial screws up and loses their case?
    [end quote]

    Most mistakes aren’t harmful to the patient, or are caught. I wish I had the analysis on malpractice suits they brought up. They had two categories (I was driving my kids around, so filtering voices, tunnels, etc. means I didn’t get everything), but one of them was a half of one percentage of the health care cost, then I think they discussed defensive medicine? I just thought it was insightful when they are honest (the author thinks lawyers should be using the law to help society, not for self-gain), about what I consider dark side of medicine and the law (the unfortunate parts that most don’t want to play, but often have to).

  • http://www.twitter.com/alicearobertson Alice

    So almost of those receiving a positive test don’t really have the condition. Is it worthwhile? What about the 0.6% that are sick but failed to get a diagnosis? So the question is how well a certain test helps pinpoint a diagnosis and who should decide that test is worthwhile. [end quote]

    That’s very interesting. Is there an easy way a patient can find information on the rate of success any test may have (without wading through a lot of reading)? I know recently our daughter had a sophisticated blood test done. When I received the test results the doctor felt they were quite good. They seemed to say a certain factor meant the cancer may be contained. The bill for the test was $2000. I asked for a biopsy and the results were that there was cancer. So, my hopes were deflated. I found myself wondering what is done with data like this……when expensive tests don’t match?

    • HJ

      Alice asks, “Is there an easy way a patient can find information on the rate of success any test may have (without wading through a lot of reading)?”

      I would suggest you ask a doctor.

  • HJ

    To put this in perspecive, the Cochrane Review estimates for every 2000 women invited to have a mammogram, 1 will be diagnosed with breast cancer and 200 will have a false positive result. The positive predictive value of mammography, using these numbers, is approximately 0.5%.

    After watching the frenzy that ensued after the USPSTF guidelines were released, I don’t trust medical societies to do what is right for me. Those with a financial stake in mammography cried the loudest. I feel lucky my FP was willing to have an intellegent conversation with me about my risk and what the new guidelines mean to me.

  • http://drpauldorio.com Paul Dorio

    “a simple fix: produce more doctors in this country.”

    If it were as simple as that, there would be no issue. But how do you get thousands of people into the medical system, and “make” them all become family practitioners, or similar primary care type docs? Since medical school, I have heard professors/doctors ask us to consider FP etc. Won’t happen in great enough numbers. And if it did, then you’d have a shortage of specialists (a guess, but logical perhaps). Ultimately, a naïve and simple thought.

    To jump down, HJ uses the Cochrane review to “calculate” a PPV of mammography that is patently ridiculous. Mammography literature is well established and demonstrates its tremendous value. Mammograms identify 30% more cancers than would otherwise be found. And the reason why the recent “frenzy” occurred is because the USPSTF “guidelines” are completely unrealistic and do not follow the majority of the evidence. Please refer to Dr Kopans’ comments for an authority, as I am just a parrot in that regard.

    The problem that I have with “evidence-based” is that typically the “evidence” is skewed to conform with someone’s agenda. Look at the recent vertebroplasty literature in the NEJM as an example. Some insurers have now latched onto those articles and have threatened to stop paying for the procedure. More recently (and previously also) there was another report that showed, once again, how valuable vertebroplasty is and how patients’ quality of life is improved by it. But I go on.

    Bottom line: you can’t just produce a report and call it “evidence.” And you can’t just make people into doctors lickety split.

  • http://www.medicalbilldog.com Dennis (Investigator/Negotiator) at Medical BillDog

    I am sick of hearing about how scared patients are of evidence-based medicine. First, because in practice, it’s utter nonsense. I’ve never heard a doctor tell a patient the evidentiary basis of a diagnosis or treatment. The closest they typically come is saying, “I’m convinced that this is the best course of treatment for your particular problem.” In the negative, about all we hear from doctors is, “Your insurance probably won’t cover this,” from which we might infer that evidence isn’t in yet or, at least, approval has not yet been granted.

    The second reason that I’m sick of this is that the study published in Health Affairs is based on a survey that used leading language to prove a non-sensical point. Of course patients believe evidence-based medicine will limit their doctors’ choices. It will limit their doctors’ choices. Only a complete idiot believes otherwise. The real problem is twofold: (1) demonstrating that some limitations are both necessary and (especially in the case of CER) beneficial to the patient, and
    (2) eliminating devastating and inhumane limitations that use evidence-based medicine to deny coverage.

    So, how do we accomplish (1)? I already answered this question in a response to another article republished by KevinMD, Comparative effectiveness research (CER) in patient care.

    As for (2), that’s a bit more complex. Dr. Reid gives one example of where such limits are a problem. And as commenter paul notes, such limits are ultimately enforced by payers refusing to cover tests and treatments that fall outside of a certain range of acceptability. Trisha Torrey cites a terrific example in her book You Bet Your Life!. The tale of Randy Stroup being denied a chemotherapy treatment because it fell outside their acceptable range of improvement. According to Fox News story on Stroup,

    Oregon doesn’t cover life-prolonging treatment unless there is better than a 5 percent chance it will help the patients live for five more years…

    Stroup appealed, and the state of Oregon ultimately covered his chemotherapy. That’s great news for Stroup, but we all know that plenty of patients fight that same battle, lose, and die early. As long as payers are allowed to set such harsh limits, evidence-based medicine will continue to get a bad rap.