When self-evident truth in medicine is systematically ignored

Some things in medicine are obvious.  Despite the endless worship of ‘evidence-based’ medicine, and the constant barrage of studies on every conceivable topic, we do certain things because we know they just seem right.  I take as evidence the fact that we daily try to save lives, devoting research time, untold gazillions of  dollars and heroic clinical effort to our continued goal of staving off death.  Why is this?  Do we know that death is inherently worse than life?  Well, since we can’t see beyond the grave, and can’t exactly engage in double-blind, placebo controlled studies about the after-life, the answer is “no.” But we assume that life is preferable to death, based on our feelings, our sense of the thing.

The same is true in our personal lives.  No one can show me a scientific study that details why he or she married a particular person.  No one can offer up a mole of affection for empiric analysis.  And yet, we don’t doubt the existence of romance, or the reality of love.

And yet, medicine is filled with situations in which “self-evident truth” is systematically ignored, and those who believe in it intentionally and often viciously marginalized.

For example, after years of being told that physicians weren’t giving enough treatment for pain, and after years of clinicians saying, “yes we are, and too many people are addicted and abusing the system,” the data from CDC says that far too many are dying from prescription narcotics, far too many infants being born addicted, and far too many people, young and old, are using analgesics and other drugs not prescribed for them.  To which many of us say, “duh!”

And then there’s the customer service model, the thing which causes clinicians to lose their jobs as satisfaction scores fall due to disgruntled patients (often upset over not receiving the drug they desired … see above paragraph).  This is a darling of administrators.  And it clearly has flaws.  As a recent article in Archives of Internal Medicine points out, physicians with very good “customer satisfaction” scores tend to have patients with poorer outcomes.  Do you think?

Of course, electronic medical records is another.  Those of us engaged in the practice of medicine on real people can tell you, EMR has promise, but in practice it consistently does three things.  Reduces productivity, takes us away from patients and results in far too much data being recorded and stored.  It needs to mature, rather than being forced on everyone from above.

There are others, of course. Board certification is beginning to look very much like a profit-generating machine, despite the paucity of evidence that it matters.  (I am board certified, so this isn’t sour grapes.)  Federal privacy laws (known as HIPAA) has left us awash in unnecessary passwords and regulations.  EMTALA, the law which protects the uninsured has probably resulted in more costs, and more loss of qualified physicians and necessary facilities than any other piece of legislation in history.  We know it …but few people are interested in studying it honestly.

All I’m saying is that physicians, and ultimately everyone, will have to mix science with good sense, and learn to embrace their own insights and powers of observation.

Studies have their place.  But their goal is the discovery of truth.  And sometimes, more often than we realize, the truth is right in front of us.

As we say in the South, “If it had been a rattlesnake, it would have bit you!”

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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