The movement toward “Evidence Based Medicine” (EBM) is founded on a few key ideas:
- First is that there is too much variation in medical practice, and variation is a bad thing. We should know what to do and do it in all cases, the idea goes. Medicine should be standardized around what is known to work.
- Next, there is only one way to determine what works and what doesn’t–using randomized, double-blind studies and measuring the effects on large populations to develop guidelines and practice protocols.
- Third, physicians who fail to follow those guidelines should be punished.
Under this scenario, the only room for debate is around the severity of the punishment. People have argued that noncompliant physicians should be paid less, have higher premiums for malpractice coverage, lose their hospital privileges, be kicked out of insurance networks, and/or have their medical licenses revoked. I haven’t yet heard anyone argue that noncompliant doctors should be thrown in jail, but it is only a matter of time.
Now come a couple of articles from the Washington Post suggesting all this may be so much hooey.
The first is a major article by Rob Stein, headlined, “New Data on Health: Studies in Confusion.” The article looks at the recent confusing and contradictory studies on hormone replacement therapy and dietary fat done through the massive Women’s Health Initiative project. The article says that in this 15-year, $725 million federally funded research study, “questionable assumptions, design decisions and unexpected developments conspire[d] to generate perplexing results.” The article quotes Tim E. Byers of the University of Colorado as saying, “We scientists are scratching our heads over some of these results, so I’m sure the general public is doing so as well.”
The article goes on to explain that some of the hypotheses of the study were flawed or became outdated during the course of the study and it was difficult to get participants to stick to their diets consistently or take their pills as instructed. Plus, the article characterizes Jacques Rossouw, who runs the Women’s Health Initiative, as suggesting, “the project may have been too short, or studied women who were too old or just too healthy.” Stein writes, “the results have produced conflicting interpretations, with competing camps seizing on subsets of data that support their views.” (Surprise!!!)
Meir Stampfer of the Harvard School of Public Health, for instance, is quoted as having never supported the low-fat-diet part of the study: “My view at the time was that this was not a hypothesis that was strong enough to warrant testing at such great expense. Other people looked at the same data and interpreted it differently.” The article said several researchers still argue “the study came close to showing a statistically meaningful reduction of breast cancer among women on the low-fat diets.” But others are noted as contending even this is meaningless because it may have been caused by reduced weight or increased consumption of fruits and vegetables, not by the amount of fat consumed.
So, who knows what this all means? And this confusion is probably more typical than not. I recently heard a physician dismiss a study that found no beneficial effect for men in taking Saw Palmetto supplements: “They tested the wrong dose,” he said.
Better Sleep on It
A much shorter article in the Post‘s “Science Notes” section suggested cookbook medicine might not be the best approach. This article reported on research by Ap Dijksterhuis at the University of Amsterdam that suggests “deep thinking” works very well with simple decisions–those with perhaps four variables–but doesn’t work very well with complex situations using 12 or so variables.
In complex situations, the researchers suggest, people make better decisions by “sleeping on it” and letting their subconscious do the calculations. The research did not focus on medical decision-making, but it is not too much of a leap to conclude that an experienced physician’s intuition may have more value than following a cookbook set of guidelines.
Feds to Grade Docs?
Unfortunately, the federal government is well on its way to discounting the value of physician intuition in favor of adopting “pay for performance” policies for Medicare. The American Medical Association has just agreed to develop “140 physician performance measures covering 34 clinical areas,” according to a February 21 article by Robert Pear in the New York Times. The agreement calls on physicians to report to the federal government on their compliance with these “quality measures.” The suggestion is that compliant physicians will be paid more for their services than non-compliant ones.
This all sounds like Motherhood and Apple Pie–who could possibly object to physicians being graded on their performance?–until you consider the unintended side effects these crude measures sometimes produce. Nursing homes, for instance, often have been criticized for non-compliance with similar “objective standards”–such as preventing their patients from falling down. Some facilities have improved their compliance records by strapping patients into wheelchairs, from which they cannot possibly fall down. Is this really a good thing?
Similarly, many pay-for-performance advocates call for the near-universal prescription of beta blockers for people with heart disease, but many people are allergic to these drugs or have other negative reactions. Research published in the Journal of the American Medical Association concluded, “Beta Blockers may be ineffective or hurt half of heart patients.” But now, instead of using their best clinical judgment, physicians will be “incentivized” to prescribe them anyway, to raise their score with the federal government.
The Arizona Daily Star published on February 26 an interesting point/counterpoint on HSAs. The contenders were Rep. Bill Thomas (R-CA), chairman of the U.S. House Ways and Means Committee, and committee member Rep. Jim McDermott (D-WA).
Thomas made an interesting comparison between HSAs and hybrid cars. As hybrids combine both gasoline and electric power, Thomas noted, HSA programs combine both a savings account and an insurance policy. He said HSAs give “individuals and families the option to lower their health care bills while saving for future health care costs.”
McDermott doesn’t offer any new metaphors, just a rehash of the same old scare tactics. He asked, for example, “Who but the wealthiest could afford to save enough money to pay the expenses resulting from a serious illness or injury before a high-deductible policy even kicked in?” And, “Do you forgo car insurance and set aside a hundred bucks a month in case you’re in an accident?” Etc., etc., etc., ad nauseum.
Source: Arizona Daily Star, “Opinions Clash on Health Savings Accounts,” February 26, 2006, http://www.azstarnet.com/sn/printDS/117446
Amish Drive Hard Bargain
The Amish and Mennonites in Lancaster County, Pennsylvania have arranged for fixed-price services from the local hospital–$16,577 for a hip replacement, $3,200 for knee arthroscopy, $7,542 for a mastectomy–according to a February 23 Wall Street Journal report. These are prices just barely above what Medicare would pay.
How did they do it? By keeping insurance companies out of it, paying 50 percent of the fee in cash at the time of admission, promising not to sue for malpractice if something goes wrong, and threatening to take their business to Mexico if the hospital didn’t cooperate.
This latter was no idle threat. The article says there are several facilities in Mexico that have a booming business taking care of Amish and Mennonite patients.
Source: (subscription required) http://www.wsj.com/article/SB11404890912458710.html
Greg Scandlen ([email protected]) is president of Consumers for Health Care Choices.