These days the moniker “evidence-based” has been attached to almost any statement about the practice of medicine and health care reform. Since a goodly number of people are really afraid of the notion of statistics, it’s very easy for anyone to slap the label “evidence-based” on a medical decision and get away with it—very few people are going to ask to see the fine print.
Thank goodness some of those people interested in fine print are writing about their findings on The Incidental Economist, a blog “contemplating health care with a focus on research, an eye on reform.”
Now there’s someone actually looking at the fine print in “evidence-based” medicine. Thank you!
The Problem with “Evidence-Based” Patient Care
The term “evidence-based” medicine implies that the conclusion based upon the data is 100 percent correct and there’s no room for variation. Use of the term encourages patients to think that whatever care they are getting (or, just as likely, being denied) somehow is 100-percent accurate. Anyone with even a hint of knowledge about statistics knows full well the results of a research study is, well, not 100 percent perfect and therefore not 100 percent correct.
There’s a fundamental misrepresentation in “evidence-based.” The term encourages those devising various rules for dispensing health care to ignore variation in the human condition. And it implies to patients that this kind of care is 100-percent correct. Crediting evidence-based medicine as the answer to everything in patient care becomes a convenient mechanism to avoid dealing with complexity.
For example, practitioners for many years have had difficulty finding a reasonably accurate test for thyroid dysfunction. Little consideration is given to the possibility that the “evidence” is based upon flawed or questionable research determining the limits of “normal.” If a few lab tests currently sanctioned for testing thyroid dysfunction fall within “normal” limits, the “evidence-based” conclusion is that there’s nothing wrong with the patient’s thyroid function. This could be true, but may be most decidedly untrue in some cases. Basil body temperature may tell one otherwise.
Simplistic Answers Cast Medical Care in Concrete
Simple answers such as “evidence-based” medicine beget simplistic patient care, which, let’s face it, leaves a large portion of the population with no care at all. Only a thinking physician with the desire to get to the bottom of a patient’s various problems can ferret out the underlying issues when the standard of care fails to turn up a diagnosis.
Dr. Ronan Kavanagh, in “A Doctor in the House,” provides a good description of what physicians do well, the very thing missing in “evidence-based” medicine:
Knowledge, and the wisdom to apply it, can only be acquired through experience. In the case of any healthcare professional, this is learned through exposure to thousands of patients in training and throughout a career.
It comes through learning how to spot patterns and clusters of symptoms, learning that many of our patients do not conform to the descriptions in textbooks (or online articles) and learning how to deal with uncertainty.
As I’ve noted in a previous post, “Novice to Expert,” Richard and Herbert Simon observed that expertise is not comprised of knowing a lot of rules, but on recognition of having seen something similar, perhaps only once before, sometimes even 30 or 40 years before. This kind of expertise cannot be reduced to a checklist, but rather requires face time with the patient, something for which physicians are not paid—a situation corporate medicine cracks a viscious whip over.
False Assumption: One Size Fits All
One of the troublesome side effects of the mantra “evidence-based” medicine is the notion that research studies will provide a one-size-fits-all solution to any problem in health care.
Looking at evidence is helpful. Checklists are valuable as guidance, and as Atal Gawunde has noted in his Checklist Manifesto, provide protocols to improve the safety of medical procedures. But as we live in an age of the sound bite, checklists have great appeal to the media—and those constraining medical care to control costs. After all, checklists make it unnecessary to THINK.
Health Care Reformers—Recognize the Elephant in the Room!
It’s time to cast some light on the elephant in the room. It’s time to recognize “evidence-based” medicine for what it is—a carefully selected array of statistics which are biased in the choice of subjects any way you cut it. Years ago, Darrell Huff wrote How to Lie with Statistics. He clearly outlined how research subjects can never be truly random, but even more importantly, cannot represent ALL patients. There is always a bias, overt as well as hidden.
Today, statistic books for “dummies” carefully school readers in how to represent data in various ways to make the charts and graphs support whatever it is the public relations department cares to promote. It’s as if today it’s assumed the “dummies” need help in how to misrepresent the data. My, how times have changed.
In the age of the sound bite, black and white answers in the form of “evidence-based” medicine are tossed around as if they represented reality 100 percent of the time. This “evidence” is used to deny health care to anyone falling outside the subjects studied, anyone suffering from a complex array of problems, or anyone needing a thinking physician to recall a single similar occurrence 30 years ago.
Denying patients care because of “evidence-based” medicine is a fine way to run a business. Saves lots of money. But it’s a disastrous way to structure health care.