Evidence based medicine?

If you can pry yourself away from C-Span and the healthcare debate for a moment, the NYT Magazine has an article this week that addresses, arguably, an even more fundamental aspect of medicine – how it’s performed and how care decisions are made. The recent rise in interest in “evidence based medicine” has been perhaps curiously controversial (at least to me) since the inverse situation would seem to be “non-evidence based medicine”. Okay, to be fair, it would more likely be “intuition and personal experience”.

The article provides some interesting insights on the history of medicine and then gets into this issue of empirical science vs. intuition.

But there is one important way in which medicine never quite adopted the scientific method. The explosion of medical research over the last century has produced a dizzying number of treatments for different ailments. For someone with heart disease, there is bypass surgery, stenting or simply drugs and behavior changes. For a man with early-stage prostate cancer, there is surgery, radiation, proton-beam therapy or so-called watchful waiting. To enter mainstream use, any such treatment typically needs to clear a high bar. It will be subject to randomized trials, statistical-significance tests, the peer-review process of academic journals and the scrutiny of government regulators. Yet once a treatment enters the mainstream — once we know whether it works in certain situations — science is largely left behind. The next questions — when to use it and on which patients — become matters of judgment, not measurement. The decision is, once again, left to a doctor’s informed intuition.

But, what’s wrong with intuition and taking advantage of experience?

“There are some real advantages to that,” James says, “and in some ways there are some real disadvantages too.” The human mind can sometimes do a better job of piecing together amorphous bits of information — diagnosing a disease, for example — than even the most powerful computer. On the other hand, human beings can also be unduly influenced by just a few experiences, like the treatment of an especially memorable patient. As a result, different doctors frequently end up coming up with different answers to the same question. Cardiologists in Davenport, Iowa, are quick to insert stents; cardiologists in Iowa City and Sioux City are not. They can’t both be right. Some people with heart disease are getting the best treatment, and some are not. The same is true of debilitating back pain, various cancers and even pregnancy.

Implications for American healthcare policy?

The health care debate of 2009 has had so many moving parts that it has sometimes seemed impossible to follow. The crisis behind the debate, though, is about one thing above all: the scattershot nature of American medicine. The fee-for-service payment system — combined with our own instincts as patients — encourages ever more testing and treatments. We’re not sure which ones make a difference, but we keep on getting them, and costs keep rising. Millions of people cannot afford insurance as a result. Millions more have had their incomes pinched by rising insurance premiums. Medicare is on a long-term path to insolvency. The American health care system is vastly more expensive than any other country’s, but our results are not vastly better.