Posts Tagged 'Evidence Based Medicine'

Decision Support, Professionalism and the Lost Art of Healing

Health care in the United States is struggling to redefine itself. We have been spending twice what other countries spend on health care, yet our citizens are less healthy. We now have legislation to create more or less universal insurance coverage, and we are about to embark on a technology-driven quest for quality and uniformity. At the same time, Americans are increasingly turning to alternative health care practitioners, mostly at their own expense, because the health care system is not meeting their needs.

In the three decades since I entered this profession the typical role of physicians has changed dramatically. In the 1980’s most doctors were self-employed and received payment directly from their patients. Now most doctors are employees who receive their salaries from organizations that collect payment from insurance companies on behalf of the patients.

With this arrangement patients have lost the power that came with directly paying doctors for their services. Doctors now have to answer not only to their patients, but also to their own employers and to the insurance companies, whose profits are carved from the difference between insurance premiums collected and medical care delivered.

Medicine has until now been considered one of the three learned professions along with Law and Theology. These three professions are said to require advanced learning and high principles. Physicians, lawyers and clergy study and interpret their material. They sometimes find themselves in a position where they are forced to disagree with others of similar training, who draw different conclusions from the same text.

It is very tempting to think that there is only one right way to do things in medicine. After all, medicine is a science, and we spend a lot of money on doctors, tests and treatments. For those who remember, Marxism was also touted as a science, yet the planned economies of the world collapsed because their scientific theory created systems that were too large and rigid to manage effectively, let alone meet the needs of their customers.

Every day I read about medical errors that only computers could avoid and alleged epidemics of unprofessional conduct, negligence and incompetence among physicians. The solution is made to seem obvious: Change the role of physicians from intellectually independent professionals to generic health care providers. Put them in front of computers that offer “Decision Support”, which is jargon for suggesting to them what to do, and then measure their compliance with the computer’s suggestions.

Even the New England Journal of Medicine recently printed an article that suggested that computers could make unnecessary the “master diagnosticians of past eras”.

Is it any wonder that so many hard-working, decent doctors are dissatisfied with their careers? Is it any wonder that the primary care specialties are having recruitment problems?

Doctors will happily do the right thing, if we show them what the right thing is, President Obama inferred after the United States Public Health Service recommended cutting back on mammography screenings.

This is an example of where we, unfortunately, stand with “Evidence-Based Medicine” (EBM) in the United States today. The mammography recommendations were changed, not because the evidence changed, but because the task force looked at the data differently.

“Evidence Based Medicine”, in my opinion, requires individual physicians to continue to act as professionals, read the literature and expert opinions with a discerning eye, look for bias and ultimately help individual patients with unique situations take the best action.

The proponents of uniformity, today’s capitalists or yesterday’s Marxists, have both failed to understand the art in what we do. Health care is like food, wine or music. The ingredients, even the recipes, may look similar, but the interpretation and delivery makes it what it is. Two different doctors can deliver the same care in theory but get different clinical results and different patient satisfaction. And two patients with the same stage of a disease may respond differently to the same treatment.

In 1996 Nobel Prize winner Bernard Lown wrote “The Lost Art of Healing”. It is still missing in many places.

No matter how technologically advanced medicine gets, and no matter what financial or administrative pressures doctors are subjected to, ours is a healing profession. Our duty is to maintain our professionalism and use our scientific training, never forgetting that patients come to us to be healed or comforted. Even our Evidence-Based treatments are sometimes only marginally better than placebo, for example antidepressants. A therapeutic relationship between doctor and patient can sometimes do more for a patient’s health than a hastily delivered, computer-generated prescription.

Physicians need to take pride in their work and act like doctors, not health care drones, who blindly and mindlessly toil for the big health care machine.

Quality or Conformity?

Yesterday I received something in the mail about how I might be judged by certain “Quality Indicators”, such as my patients’ mammography rate. This struck me as very odd, since just a few weeks ago the U.S. Public Health Service Taskforce reversed their longstanding recommendation that all women should have annual mammograms from age 40.

This is a striking example of how yesterday’s truths are tomorrow’s fallacies in modern medicine. A doctor who orders annual mammograms this month could be viewed as practicing poor quality medicine, even though the same behavior might have earned him or her bonus payments and honorable mentions last month.  

I think it is time we speak honestly about what the agenda really is here. If we, or those who pay us or regulate us, choose quality indicators that are not based on solid scientific principles, but instead on expert opinions that could – and do – change at any moment, we are not measuring quality at all. What we are measuring and rewarding in that case is conformity. How fast and how consistently today’s physicians can implement new guidelines is certainly easier to measure than how well their patients are feeling.

We aren’t measuring how often doctors make the correct diagnosis on the first visit or how well they handle difficult clinical situations. We aren’t measuring how often we are able to reassure or comfort another human being who would otherwise keep circling within the health care system at great expense in search of peace of mind.

No, the things we measure are only the underpinnings of quality in health care. It is fine to measure doctors’ compliance with official guidelines, but we need to look well beyond such low hanging fruit if we want to be serious about quality. 

Frankly, there are ways we can let our office staff, our disease registries or Electronic Medical Records handle a lot of the housekeeping items people think of as quality indicators. The quality measures of physicians’ work would then reflect how we practice the art and science of medicine. We need to look more to clinical results (outcomes) and appropriateness of care.

Just like in school, we can strive to master the subject or just pass the test. If we just want to pass the test, we can change the subject when our patients bare their souls to us, fumble with the chart or peer into the EMR and start talking about tetanus shots and cholesterol and mammograms (or perhaps why we won’t order a mammogram), or we can push the paper chart or computer screen aside, look them straight in the eyes and say:

“We’ll let the system catch up with you about those things. Tell me what’s bothering you…”

See You Next Time

Can you imagine a doctor telling a heart attack survivor:

“That was a close call, but I’m glad you made it. I’ll see you next time you have one. Oh, by the way, you might want to watch that cholesterol.”

I thought not. Yet, that is how most of the one million kidney stone cases are handled every year in the United States at a cost reported to exceed four billion dollars.

Kidney stone pain is said to be one of the worst pains a person can experience. In medical school we were taught that patients with a ruptured appendix are likely to lie perfectly still on the exam table whereas kidney stone patients are in such agony that they are unable to stay long enough on the table for you to examine them.

We have all kinds of technologies available for kidney stone removal, all of them expensive. Prevention, on the other hand, is cheap but seldom done. Cynics may say that there are no incentives in this country to prevent diseases that provide steady work for physicians who treat them.

Over the years I have seen public awareness and special interest groups crop up for just about every disease, even rare ones like SCID, Asperger’s and Rett Syndrome. Common things like avoiding recurrent kidney stones seem to get less media attention.

Kidney stones are made up of uric acid (the same compound responsible for gout) or salts containing calcium and another ingredient like oxalate, phosphate or struvite. Regardless of stone composition, recurrences can be partly prevented by simply drinking more water, which dilutes the stone-forming chemicals. Interestingly, there is a “kidney stone belt” in the southern part of the United States that is said to be expanding northward as a result of global warming, with projections of a 25% increase in kidney stone cases by the year 2050.

The Calcium Paradox

Depending on the chemical composition of kidney stones and levels of urinary excretion of key ingredients, specific dietary interventions and medications can help reduce a patient’s risk for recurrent stones. Doctors, like everyone else, however sometimes jump to conclusions. Some things seem so obvious that nobody questions them. Then, when scientific research proves our assumptions to be wrong, we refuse to believe, or perhaps we just forget what we have learned. This is at the core of what we call Evidence Based Medicine.

It was long assumed that if you restricted a person’s intake of calcium, the risk for kidney stones would decrease. The New England Journal of Medicine reported in 1993 that the opposite was true; a low calcium diet increases kidney stone risk. I seem to remember hearing the same thing during my training in Sweden long before then.

The reason for this calcium paradox seems to be that a low calcium diet causes more ingested oxalate in the intestine to exist in a free form, rather than attached to calcium. The free intestinal oxalate is more easily absorbed, leading to more oxalate in the urine, where it can combine with even small amounts of calcium to form a kidney stone.

Yet, I often hear that kidney stone patients are told by their doctors to restrict their calcium intake. I also hear both doctors and patients make general statements about the effects of fluid pills (diuretics) and vitamin C. Without knowing what type of stone a patient has, such generalizations are simply not helpful. 

Physicians have an obligation to help patients avoid illness when there is good evidence available to guide us. Kidney stone prevention is not as glamorous as blasting stones with lithotripsy. As with any disease prevention, the way you know it works is that nothing happens. Any physician who has faced a kidney stone patient writhing with excruciating pain can appreciate that nothing happening is more humane than “See you next time”.

Cholesterol Guidelines and the Bachelor with Platform Shoes

 

I have read that tall bachelors have more dates than short ones, and until recently it seemed obvious that men with low LDL cholesterol would have fewer heart attacks than men with higher levels. So what happens when a vertically challenged young man dons a pair of ABBA style platform shoes? And what does this really have to do with cholesterol?

Let me start from the beginning.

In medicine today, there are two mantras, even buzzwords: Evidence Based Medicine and Clinical Guidelines.

To practice Evidence Based Medicine is to do precisely those things that are proven by rigorous research to help the patient. Examples include giving heart attack survivors certain medications (Beta Blockers) or to give aspirin to patients with TIA’s (often called “Ministrokes”).

Clinical Guidelines often involve reaching numerical targets, and this is the first tip-off that we’re on much shakier ground. Keeping a diabetic’s blood pressure under 130/80 may be a good thing to do, but not if the person has a history of fainting from low blood pressure when standing up too quickly.

A dramatic example of failed guidelines came with the recent publication of the ENHANCE study (New England Journal of Medicine, April 3, 2008). The National Cholesterol Education Program has long recommended keeping the bad LDL Cholesterol under 70 in high risk patients, like those who have had a heart attack or a bypass procedure. The problem with this guideline was that it created a situation where doctors faced with an LDL slightly above “target” would abandon high doses of, for example the proven drug Lipitor, and switch patients to moderate doses of Vytorin, which contains a less powerful “statin” drug and an until now unproven new drug, called ezetimibe (Zetia).

The new drug, introduced in 2002, lowers cholesterol by blocking intestinal recycling of old cholesterol from the body’s different cholesterol-based hormones etc. In the beginning, there was no proof that ezetimibe lowered heart attack rates or limited cholesterol buildup in our arteries, but there was something very promising about the drug; it not only helped lower cholesterol, but it also reduced levels of CRP, or C-reactive protein, an inflammation marker that closely follows heart attack risk.

So the number crunchers started to put pressure on doctors to reach numerical targets, and television ads promoted the dual action of Vytorin.

Fast forward to a couple of months ago when, after a billion dollars in sales, the new drug looks no better than platform shoes; better measurements, but same number of dates (in this case meeting our maker…), so to speak. The ENHANCE study didn’t count deaths or heart attacks, but it did measure thickness of cholesterol buildup in arteries, and there was no difference between plain Zocor (simvastatin) and the combination drug (Vytorin). Factor in that you can buy simvastatin for $4/month at some supermarket pharmacies, while Vytorin costs 2,500% more (yes, do the math; $100 divided by $4 times 100%!).

The lesson here is that the guideline writers failed to think about what evidence we had about how patients achieved their goal numbers, just like the guy in the ridiculous shoes only thought he was closer to eye level with the girl he was trying to impress.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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