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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  • http://twitter.com/drheatherrupe Heather Rupe


  • http://profile.yahoo.com/JYG5LDGOGYRJZZAWWHYSNMAVLQ Neil

    HIPAA. Are you really a doctor?

    • http://www.kevinmd.com kevinmd

      I fixed it.  Thanks for pointing it out.

  • http://www.facebook.com/profile.php?id=1536821513 Edwin Leap

    Oops@yahoo-JYG5LDGOGYRJZZAWWHYSNMAVLQ:disqus   Sorry, dear readers, but I seem to have spelling block whenever I write HIPAA!

  • http://www.yupana.ca davemacdonald

    This is great, Edwin. What you’re saying about obvious truths is important. Working closely with a pharmacist of late, evidence plays a major role in the bastardization of healthcare provided by drug companies, but it shouldn’t dominate absolutely everything we know about day-to-day health.

  • UncleStu

    “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.”

    Sorry to disagree but:
    - That law was not designed to rfeduce costs. It was designed to protect the uninsured – period. Sorry you don’t like that.
    - Saying that EMTALA resulted in more loss of qualified physicians and facilities etc, without any facts to substantiate it sounds exactly like the kind of nonsense that the so-called “tort reform” and “malpractice reform” advocates try to foist on the public.

    That paragraph made me reread the entire article more critically, and I concluded that  it is almost all BS.

    • Gil Holmes

      I missed where he claimed that EMTALA was enacted to reduce costs. Nowhere does he say one word that would disagree with your first bullet point.
      And in your second bullet point you commit the very sin you accuse him of. Deride an entire concept with not one whit of evidence.
      And I am unsure how not liking what he said in 1 sentence(not a paragraph) changes the rest of his post.

  • http://profile.yahoo.com/RI2PCIY7W7NRN5LBCBFQVHNW7M Doc P

    Excellent, Ed!  Too often we are shoved to do some things with no proof it will help (EMTALA, HIPAA, EMR, mandatory hospital supplied translators for those with “Limited English Proficiency”, etc). In my assessment, it seems these are usually driven by some interest group (read – money to be made) rather than some true solution. I do not doubt that some help provide better care (translators), but who really pays for this? The faceless third party payors (i.e. us!) in most cases.

    When will we, as health care PROFESSIONALS, stand up for our patients and say with one voice that we will do or not do something because we are doing what is right for our patients and thereby providing good medicine?

    Thanks again, Ed

    • Payne Hertz

       So let me get this straight: denying people treatment if they can’t pay, violating their right to privacy, continuing to use 19th century office technology that results in hundreds of thousands of medical errors every year and refusing to communicate with patients in their own language are all examples of “providing good medicine” to you?

      No wonder our medical system sucks.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      “When will we, as health care PROFESSIONALS, stand up for our patients…..”

      Yes. I’ve been asking this question here many times.

      Of course, you will have to fine tune the message, so it is the patients you stand up for…. I would suggest leaving EMTALA and certain portions of HIPAA out of this message.

  • http://www.facebook.com/profile.php?id=100000026919705 Corazon Tan

    well said.
    as for board certification,boards of medicine  or the states should tally the difference about how  many catastrophic events  and malpractice cases  of boarded and non boarded(certification)  physicians incur in their practice   each year  and see if  board certification makes any difference?
    Lab.tests,unnecessary workups  should be tailored according to medical indications ,most physicians routinely order them so patients  don’t sue them(defensive medicine is the word),this i think is one of the major expence  we can do without . 

  • http://www.facebook.com/people/Tom-Fitzsimmons/1405121136 Tom Fitzsimmons

    So, get another job. This is more and more turning into a physician whine festival. Grow the (heck) up for gods sake. It’s a difficult world and even more so when we think of ourselves as under appreciated knights in shining armor. It’s you, Doc, that’s missing the evidence.

  • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

    True, certain things are beyond proof–life after death, love of another and many other spiritual experiences.  However, I like my medical care to be empirically based.  I do admit that sometimes there is not enough empirical evidence available and best hunches must me used.  Yet, when proof and evidence do appear for clinical practice, I hope my physician adopts them.  For instance, real physicians in the 1950′s appeared in TV ads selling a variety of brands of cigarettes.  I really don’t think any physician would do so now, given the empirical evidence of the evils of tobacco.  The advance of research in the 60′s and 70′s on tobacco use enlightened clinicians and the general public on the ills of tobacco and clinical practice followed.  Let us continue advancing medical practice in the present in the same way.

  • http://www.facebook.com/people/Tom-Fitzsimmons/1405121136 Tom Fitzsimmons

    OK, further thought-many had reservations about EMR for just the reasons you pointed out but it was glossed over. Too much information that can and will (and is) being accessed by the wrong people. It detractacts from the office visit, too. Nobody points out though that the dr could still do his notes on break from pts like it was done, not on the spot, trying to listen and type at the same time. Narcotics have to be dealt with. A little legalization here would save millions in cost, but what you should remember is that even when you think you are scammed and abused you are actually treating the symptoms of another disease entirely. Regulate and provide treatment options when the time is right and I think you will see the problem of addicts decrease. Oh, and you might want to stop poisoning our junkies with tylenol and unsafe anti-inflammation drugs that can present as much of if not more of a problem than the actual opiate. Let’s get rid of codeine-it’s a poor drug that is unpredictable and can kill nursing babies.
    I haven’t seen a dr professionally in about 5 yrs. I like them as a group and having worked in medicine I know them pretty well and I enjoy their company but aside from the natural anxiety I feel from having no health insurance (I’m too old to afford it, too young for medicare), I also get a feeling of relief from being separated from being a pt.

  • Payne Hertz

    I’m not sure what to do at this point to not run afoul of this site’s censorship practices. You’ve deleted what, 30 to 40 of my posts so far? Apparently the “self-evident truth” you claim can’t stand up to even minor scrutiny from lay people, let alone a more detailed dissection from an expert in the field.

    Considering the anti-patient animus of  this article, this site and the majority of its commentators, you can’t possibly cite my tone as a reason for deletion, as I take pains to keep my posts well below the level of invective usually displayed here.

  • http://profile.yahoo.com/JZ3QJKN73LU2XH4A6ODOVL3IYI Jan

    “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.”

    Western medicine is based on the scientific method. The scientific method is based on evidence backing up insight and observation. If you would prefer a profession based on belief, please consider the clergy.

    “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.”

    I think you are saying studies are worthwhile, but verification of a “truth” through controlled studies takes too long to complete.

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

    “Snakes always rattle just before they strike”
    ~Robert Hunter

  • http://twitter.com/dalecoymd Dale Coy

    Well said.  Roger Hartley in Morton’s Fork agrees.  He is a doctor who can’t take it anymore.

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