Tuesday, August 18, 2009

Humanism and Evidence-Based Medicine

Prelude: This is my comment on an article in The Health Care Blog, entitled "Can Social Commentary Save Health Care?" dated August 17, 2009. The article was written by Daniel Palestrant, MD, founder and CEO of Sermo.com

In 1988 I published And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota. At the time, I was editor-in-chief of Minnesota Medicine, the monthly journal of the Minnesota Medical Association. I was concerned managed care would drive doctors out of independent primary care, reduce them to mere functionaries of corporate interests, weaken doctor-patient relationships, and discourage medical students from entering HMO dominated medicine.

As it turned out, I was partially right. Independent primary care physicians are on the wane; solo practice is dead as a doo-doo bird in Minnesota, most primary care physicians there now work as salaried employees of hospitals; practitioners everywhere are a threatened species, with a current shortfall of 50,000 nationwide , estimated to reach 200,000 in 10 years; current and future medical students are more interested in specialties with better life styles and higher pay.

Meanwhile, partly as a reaction against the time-consuming bureaucracies surrounding data-based pre-authorization policies, the humanism movement, i.e. patient-centered care with doctors engaging patients as partners in shared decision-making is on the rise. Many doctors are pulling out of HMO and PPO contracts, not accepting new Medicare patients, dealing with patients directly in concierge and cash-only practices, or going to work for hospitals in jobs where they don't have to bother with health plans.

Also on the ascendancy is evidence-based medicine, i.e., data-based care. In some respects, care requiring documentation has replaced care requiring clinical judgmetn as a mainstay of clinical practice. In How Doctors Think, Jerome Groopman, MD., a professor of medicine at Harvard, has this to say,

Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment – distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctors needs to think outside their boxes, when symptoms are vague, or multiple and confusing or when test results are inexact. In such cases – the kinds of cases where we most need a discerning doctor – algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they constrain it.

Similarly, a movement is afoot to base all treatment decisions strictly on statistically proven data. This so-called evidence-based medicine is rapidly becoming the cannon… But today’s rigid reliance on evidence-based medicine risks having the doctor chooses care passively, solely on the numbers. Statistics can’t substitute for the human being before you; statistics embody averages, not individuals.

According to a recent article in the New England Journal of Medicine (“Keeping the Patient in the Equation – Humanism and Health Care Reform,” August 6, Page 554-555). Groopman and Pamela Hartzband, another Harvard academic say the humanism movement and the evidence-based practice movement are on collision course.

Evidence-based medicine is based on the premise that, given the best available data and clinical protocols and guidelines and standardized procedures and guidelines, outcomes will improve and medicine will rest on a scientific foundation.

Furthermore, evidence-based care plays to the strengths of Interment medicine, viz, health 2.0, clinical algorithms, data mining, and predictive modeling.
Evidence-based medicine has a ring of logic and credibility, and it gives critics rational tools to contain costs while improving care.

But it has hidden flaws too. It is based on retrospective statistical generalities rather than individual patient and doctor expectations during a doctor-patient encounters; it may reduce the patient-doctor exchanges to statistical exercises based on sometimes equivocal cost effectiveness data; it may handcuff doctors who wish to give desperate patients one last hope of cure; it may put federal and private bureaucrats in the position of making clinical decisions based on retrospective data; it assumes ubiquitous data loaded and data acquiring EMRs will improve care and will be cost-effective, which has not been the case in the United Kingdom (“Effects of Pay for Performance on the Quality of Primary Care in England,” NEJM, July 23, 2009, page 368- 377).

According to British researchers in the same article, using computers to meet quality criteria may disrupt the continuity of care. Finally, so-called evidence-based care fails to address the main health reform concerns of American physicians.
As noted above, according to Palestrant, founder and CEO of Sermo.com, the four main health reforms needed as reflected in the opinions of 110,000 physicians participating in Sermo, are:

1. Reducing unnecessary tests and procedures through tort and malpractice reform,

2. Allowing doctors to spend more time taking care of patients by making billing more transparent and streamlined (creating an alternative to CPT codes)

3. Insurance reform to ensure that physicians are making medical decisions with their patients, not insurance company administrators.

4. Revising the methods used for calculating reimbursements so that there will be enough qualified physicians to provide patient care.

These concerns have merit. They are not trivial and are not addressed in the House Bill, H.R. 3200. I would add that unless these concerns are addressed, physician demoralization will continue ; the physician shortage and the number of physicians not accepting new Medicare and Medicaid patients will surely grow. Universal coverage without access to physicians will be meaningless.

Finally, I bring attention of readers to a chapter in my book, Obama, Doctors, and Health Reform, on the work of Dr. Palestrant, in which I make the following observations based on a conversation with him.

1) Through a web of rules and regulations, and outdated reimbursement rules, the deck is stacked against physicians and discourages innovations.

2) A genuine and deep physician “supply and demand” disequilibrium exists for American physicians.

3) The “perfect information" quest, based on retrospective health plan and Medicare claims data, is unrealistic.

4) A shift to consumer-centered care, making them conscious of what they’re paying fork, market transparency of prices and outcomes, and personal responsibility is underway.

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