A new report, “How Technocrats Are Taking Over the Practice of Medicine: A Wake-up Call to the American People,” written by Twila Brase, president of the Citizens’ Council on Health Care (CCHC), challenges the “increasingly touted theory of evidence-based medicine (EBM).”
Calling evidence-based medicine “managed care masquerading as science” at a special press briefing for the release of the report in December, Brase told reporters in St. Paul, Minnesota, “control over medical decisions is being shifted from doctors to data crunchers; from professionals at the bedside to bureaucrats in big offices.”
According to Brase, EBM “has become an ever-present mantra in health care publications. In the last few years, legislators have gotten hold of it and proposed legislation or actually placed the term into law.”
For example, EBM guidelines are found in Maine’s Dirigo Health Reform Act, signed into law in September 2003, and in the California Workers Compensation Reform of April 2004 (SB 899). EBM provisions have made their way into several health-related laws in Minnesota, and Colorado considered an EBM measure in 2004 but did not pass it.
“If evidence-based medicine is not understood for what it is, managed care [organizations] will use it to solidify [their] control over medical decisions and the practice of medicine. Managed care will become the law of the land,” said Brase at her December press briefing.
Term Has Become Euphemism
“Evidence-based medicine has become a euphemism for managed care,” Brase told reporters. “It’s still care-restricting and physician-controlling, but the term gives leverage to care-restricting decisions. Behind this term, insurers can continue to impose limits on health care.
“But instead of explaining their decision by saying the service is not necessary or not cost-effective, they can say it is not scientifically sound. [That is] a much stronger argument, and much more difficult for the public to fight against. After all, who holds almost all the data? The insurers and the government–those who pay the bills.”
Evidence-based medicine is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” (See Evidence-Based Medicine (Churchill Livingstone, 2000) by David L. Sackett.)
However, Brase said, individual patients are not the focus of EBM and its standardized practice guidelines. “The guidelines are created by accessing private medical record data, aggregating the data, and synthesizing it into population-based treatment algorithms for all physicians to use on all patients,” said Brase. “EBM is group-think medicine.”
Greg Scandlen, director of the Center for Consumer Driven Health Care at the Galen Institute in Washington, DC, described Brase’s paper as a “landmark analysis of the attempt to bureaucratize medical practice.”
Myriad Concerns Raised
The 22-page, extensively documented report points out not only the rationale espoused by proponents of “evidence-based medicine,” but also the myriad concerns of critics of the practice. For instance, supporters say EBM and evidence-based practice guidelines (“best practices”) are needed to, among other things, contain health care costs, reduce variation in physician practice, keep physicians up to date with the latest research, and reform medical malpractice.
According to OpenClinical, a UK-based international organization created to promote awareness and use advanced knowledge management technologies for patient care and clinical research, EBM has three main advantages:
- It offers the surest and most objective way to determine and maintain consistently high quality and safety standards in medical practice.
- It can help speed up the process of transferring clinical research findings into practice.
- It has the potential to reduce health care costs significantly.
Critics, however, are cited in the report as saying EBM results in:
- overly rigid standards of care
- restrictions on medical practitioners’ professional freedom and judgment
- imposition of personal agendas by those choosing which research to do, picking between the various studies and calling it “evidence,” and writing the guidelines, as well as administrative bias by administrators interpreting the guidelines. (“The decision makers and the potential for agendas and bias are numerous,” said Brase.)
- rationing of health care services
- and politicization of medicine.
Brase’s report quotes, for example, Dr. Uwe Reinhardt, an economist at Princeton University, from a 1999 published conversation on EBM. Reinhardt said, “My fear is that medicine will slide into the same intellectual morass in which economists now wallow, often with politics practiced in the guise of science. In medicine, it might be profit-maximizing in the guise of science.”
Evidence Is Suspect
Besides the failure to view patients as unique individuals, practice guidelines have other problems, the report notes. The guidelines often fail to make explicit how recommendations are devised, and they rapidly become outdated, the study points out.
Brase writes, “In 2000, a group of researchers determined that more than 75 percent of the guidelines developed between 1990 and 1996 needed updating. In addition, they discovered that half the guidelines were outdated in 5.8 years.”
Even the “evidence” of evidence-based medicine is suspect, Brase says. Researcher bias, disagreement in defining “best evidence,” incomplete reporting of research results, and conflicting findings are just some of the problems with research relied on for determining “best practices” or EBM, Brase told reporters.
Quoting the 2004 Institute of Medicine publication, Patient Safety: Achieving a New Standard for Care, Brase notes the difficulty of determining what is authoritative evidence: “There are gaps and inconsistencies in the medical literature supporting one practice versus another, as well as biases based on the perspective of the authors, who may be specialists, general practitioners, payers, marketers, or public health officials.”
Finally, critics have claimed EBM changes what it considers to be science in order to suit the goals of its proponents. Gary Belkin, M.D., Ph.D., author of The Technocratic Wish: Making Sense and Finding Power in the “Managed” Medical Marketplace, argues that different versions of “scientific credibility” can be embraced to change the power structure in health care.
EBM, he told Health Care News, is not just about science but about the destructive industrialization of medicine.
Harm Could Be Huge
Despite these concerns, Brase reports insurers, state governments, employer groups, and the U.S. Congress have begun implementing “pay-for-performance” strategies including the monitoring of physicians through medical record surveillance and the issuing of compliance reports to pressure physicians to cooperate with EBM “guidelines.”
In the process, practice guidelines essentially become practice directives, which puts individual patients at risk, according to Brase and other critics of EBM.
Brase’s report quotes Dr. David M. Eddy, M.D., Ph.D., who warns, “If an individual physician and a patient make a wrong decision, that patient will be harmed, but the damage will stop there. In contrast, practice policies are intended to influence thousands, even millions, of decisions. If a policy is wrong, the harm can be huge.”
May Hasten Rationing
Brase states that EBM may also hasten rationing of health care. In her study she notes the National Institute for Clinical Excellence was created in England in 1999 to, among other duties, provide guidance on medical “best practices.” A 2003 paper by Syrett Keith of the University of Bristol, “A Technocratic Fix to the ‘Legitimacy Problem’? The Blair Government and Health Care Rationing in the United Kingdom,” in the Journal of Health Politics, Policy, and Law (August 2003: 28(4)), called the effort a “technocratic approach” and a “means for scientifically depoliticizing the rationing debate.”
The Brase report provides readers with a brief history of EBM-type medical guideline development and legislative action on guidelines, including the Clinton Health Security Act, state legislative initiatives since the early 1990s, and the Medicare Modernization Act of 2003. The study notes that concerns about rising medical malpractice claims have caused policymakers to consider standardized practice guidelines as a means of protecting physicians against litigation.
Others see the promise of malpractice relief as a “political chip” to use in gaining physician support for the guidelines.
Legal Problems Remain Likely
Some legal experts believe guidelines will not protect physicians in court cases anyway. Brase’s report quotes Daniel W. Shuman, J.D., as saying, “Almost always, the health care people talk about population-based evidence, and almost always, the legal people talk about evidence based at the level of the individual.”
Other analysts note constitutional issues have emerged from state laws that allow physicians, but not patients, to use guidelines as evidence in court.
Brase’s report includes statistics on guideline availability and costs of guideline development. The development cost, the report notes, depends on whether guidelines are developed and updated by the public or the private sector. One documented source reveals guideline production costs to be $80,000 to $100,000 unless the government does it, in which case the cost nears $800,000.
Implementation Costs Are Unknown
The U.S. government currently provides funds for guideline development to 13 designated Evidence-Based Practice Centers. However, no studies have measured the cost of guideline implementation, and some analysts say it is not clear the guidelines save money.
Brase emphasizes her belief that “evidence-based medicine” is not the objective, purely scientific tool its name suggest. Instead, she says, “EBM is an intrusive encroachment on the patient-doctor relationship and the practice of medicine; an encroachment that policy makers are turning into legal requirements.”
Brase concludes the study with a strong warning to the American people: “The evidence-based medicine initiative involves a technocratic takeover of the practice of medicine through data collection, guideline creation, clinical surveillance, pay-for-performance strategies, and centralized decision-making. In short, EBM is aimed at stopping the heart of health care–the compassionate, first-do-no-harm, to-my-own-patient-be-true ethics of medicine.”
Susan Konig ([email protected]) is managing editor of Health Care News.
For more information …
The full text of Twila Brase’s report, “How Technocrats Are Taking Over the Practice of Medicine: A Wake-up Call to the American People,” along with an executive summary, are available online at http://www.cchconline.org/pdfreport/.
