The Main Obstacles to Obama's Comparative Effectivness Plan: Doctors and Patients, Not Necessarily in That Order

Let me begin with notable and quotable remarks from this week’s press.

• What if physicians could make decisions about which drugs, devices, and treatments to use based on objective research into which options were most effective?
Elyas Bakhtari, “The Manufactured Outrage over Cost Effectiveness Research,” Healthleadersmedia.com, February 26, 2009

• It’s hard not to scream when you see how many physicians, pharmaceutical companies, medical device manufacturers, and lately hysterical conservatives seem to have science or ignore it. These days the science that inspires fear and loathing is “comparative effectiveness research” CER, which is receiving $1 billion under the stimulus bill President Obama signed.
Sharon Begley, “Why Doctors Hate Science, Newsweek, February 28, 2009

• You can make policy changes till you’re blue in the face, but if patients and doctors don’t change the way think about medicine, you’ll never change medicine.
David Newman, MD, Emergency Room Physician and Author of Hippocrates’ Shadow: Secrets for the House of Medicine (Simon and Schuster, 2008, as quoted in the New York Times, March 2, 2009

• At the heart of reform is a plan to cut costs, in part by trying to discern which treatments really work. President Obama’s economic stimulus includes $1.1 billion for studies that will ask about the comparative effectiveness of expensive procedures versus less effective ones. For instance, with certain types of injuries, does surgery work better than physical therapy? Are new higher priced drugs any more effective than their generic predecessors?
Tara Parker Pope, “ A Hurdle for Health Reform: Patients and Their Doctors, “ New York Times, March 2, 2009

Most of you reading these quotes might ask,” Why in the world would patients or doctors oppose objective comparative effectiveness data showing what treatments work?

After all, isn’t medicine pure science? No, it isn’t.

Medicine is a mixture of science and art, how to keep and please patients, and how to respond to patients who want something concrete , most often a prescription, done for them. Doctors report that 37% of patients demand a prescription.

Medicine has vast areas of gray which rests on the doctor’s discretion, for which there is no clear cut action. Doctors and patients are creatures of habit and have certain expectations, such as a CAT scan or EMR for joint, back, or mysterious abdominal pain. And many doctors and some patients have a lawyer in mind should something not be done.

It gets even more complicated.

• Some doctors simply like to try new drugs to see if they are more effective than the old ones, such as diuretics rather than the new highly touted anti-hypertensives.

• Some patients demand antibiotics for ear aches, sore throats, upper respiratory infections, bad colds, and bronchitis, even though these problems are usually viral in origin.

• In American society, physicians and their patients, are in a hurry and like to see something concrete done, thus they tend to use prescriptions, procedures, and imaging as surrogates or substitutes for thoughtful discussions about options and preventive measures.

• Doctors are paranoid about the government “practicing medicine,” often called “cookbook medicine,” and not paying for procedures the federal bureaucracy deems inappropriate or ineffective, even though doctors and patients may think otherwise.

• Patients are heavily influenced by advertising, particularly of drugs promoted on television, that promise sexual satisfaction, lowering of cholesterol and blood pressure, or relief of pain.

Life and medical practice get complicated, and these complications may have little to do with science or objectivity and more to do with accustomed behaviors.