The lesson here is that there are huge gaps in the scientific evidence guiding physician decision-making, and it wasn't until healthcare-quality gadflies like David Eddy began to demand to see the evidence that we learned about those gaps. This revelation has had at least two beneficial effects: it informs us about the lack of evidence so that we can be more realistic in our expectations and more aware of the uncertainty in medical decision-making, and it exhorts the medical community to search for better evidence.
"Nothing should be affirmatively promoted unless there is good evidence of at least some benefit," writes Eddy. It is simply amazing that applying such a statement to modern medicine represents such a ground-breaking development. But it has literally changed the face of medicine.
Excerpted from Demand Better! Revive Our Broken Healthcare System by Sanjaya Kumar and David B. Nash. Copyright © 2011 by Sanjaya Kumar and David B. Nash. Excerpted with permission by Second River Healthcare Press.
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Add CommentThere is a distinction between academic achievement, intelligence, and character. They are not, necessarily, one in the same. An individual, inclusive of a medical practitioner, may be extremely intelligent and have an excellent medical education but have a weak character. If that is the case, medical decision making will be poor despite the high intelligence and excellent medical education. Temperament and character, therefore, plays an important part in the quality of care provided by a health care professional.
Reply | Report Abuse | Link to thisThe same holds true for other professional endeavors inclusive of law, the military, and politics.
Kind of like car repair, only worse.
Reply | Report Abuse | Link to thisStay healthy my friends!
Great post. A critical question for patients, professionals, and payors is "How do you know your recommendation is the right one?" If the answer is "experience" you know the data base the doctor is working from. If he or she references research, check it out.
Reply | Report Abuse | Link to thisPatients, colleagues, and regular folks rarely ask "how do you know?" in a way that doesn't create a challenge to integrity. But we have to be able to ask in order to participate in the decision making process.
If your colleague or doctor fudge the answer or get insulted, you may have the wrong partner.
Successful collaboration whether with your doctor, a team mate, or a business partner, needs an agreed upon approach to be successful. Without agreement on "how" a collaboration will work, it's impossible to avoid rough waters. Approach, one of 7 Factors for successful collaboration http://bit.ly/fNScqL
"...Why are so many physicians making inaccurate decisions in their medical practices? It is not because physicians lack competence, sincerity or diligence, but because they must make decisions about tremendously complex problems with very little solid evidence available to back them up..." Ummmmmm, wrong! I can tell you from ten years of first hand experience where I was given countless xrays, MRI's, had seven useless surgeries, saw dozens of doctors and specialists. I can tell you most of this was precisely due to a lack of diligence! It turns out my problem was a simple, but dangerous food intolerance causing widespread inflammation in my muscles and nerves. Yet, not one of the conventional doctors and specialists even mentioned such a possibility. Worse, they never followed up to see how I was doing except to chart recovery after surgery. The fact that my condition got no better seemed to be more of an annoyance to them. Get this! at least half of the doctors I saw told me they would research the problem and get back to me, or that they would consult someone and get back to me, but only one ever did. ONE! Finally, it was a naturopathic doctor that discovered what was causing my severe pain and disabilty. And she got it right after just a couple visits and a few blood tests. I almost died due to a system that is based on numbers of patients, numbers of procedures and greed. Diligence? That's not even funny.
Reply | Report Abuse | Link to thisre: <i>Recent surveys by the Healthcare Information and Management Systems Society (HIMSS) reveal that an increasing number of hospitals and healthcare organizations are adopting technologies to keep up with the flow of research, such as robust, computerized physician-order-entry (CPOE) systems to ensure appropriate drug prescribing.</i>
Reply | Report Abuse | Link to thisI knew a pitch for computers in medicine was coming. That's it's coming from HIMSS, the industry trade group, is no surprise.
That Scientific American would publish such a statement - considering the evidence! - is a surprise.
The former Board Chair of HIMSS, Barry Chaiken, MD, MPH, FHIMSS said it best in July 2010:
http://histalk2.com/2010/07/19/histalk-interviews-barry-chaiken/
... We’re still learning, in healthcare, about that user interface. We’re still learning about how to put the applications together in a clinical workflow that’s going to be valuable to the patients and to the people who are providing care. Let’s be patient. Let’s give them a chance to figure out the right way to do this. Let’s give the application providers an opportunity to make this better.
In other words, computers in medicine are themselves experimental, and we don't have a solid evidence base we know what we're doing, or that they actually help.
See "An Updated Reading List on Health IT" at http://hcrenewal.blogspot.com/2011/02/updated-reading-list-on-health-it.html for more on that issue. The evidence base does not looks as promising as the opinions of the pundits suggest.
S. Silverstein MD
Drexel University
Philadelphia, PA
http://www.tinyurl.com/HITfailurecases
The solution to this problem lies in the same approach as education: outcome-based evaluations resulting in better pay for the good ones, and more education and supervision for the less expert.
Reply | Report Abuse | Link to thisI find this comment disingenuous. I've been working toward health care computerization and digitization of health records SINCE 1993!
Reply | Report Abuse | Link to thisIf doctors are so resistant to change, then why do we expect them to keep up with medical discoveries?
I regularly email my various specialist physicians with up to date information on what ails me, because I know they will at least know one patient that might be affected, and the young physicians poke the "Reply" button and say thanks.
If they don't I start working on a new physician. At Kaiser, you can choose your physician, and tell the hospital why you did.
We can't wait for all the old doctors to die off before we get a well-educated staff. Part of the high pay for doctors and teachers is the presumption that they will keep up with the field.
I have no objection to the high pay, but high skills must be the qualifier!
This article has echoes of Lynn Payer's book "Medicine and Culture", which compared systemic approaches to treatment in US, UK, Germany and France, finding that the differences in approach were cultural, not scientific.
Reply | Report Abuse | Link to thisUS medicine is interventionist, using more tests and more medical equipment. Fee for service gives incentive for more services. The capitation system in UK pays doctors for the number of registered patients. The incentive is to hold back on procedures unless there is a clear clinical need. In the US there is a fetish about avoiding exposure to health risks, while the French believe exposure is an essential part of building up immunity. Heart problems which in the US would result in surgery are treated in Germany with pills.
Despite widely divergent medical approaches, life expectancy in each country is about the same and people die of approximately the same causes.
What these countries share to varying degrees is what I call Neglect of Context, a research focus that attributes cause to active agents (the perception of which varies from culture to culture), largely ignoring the context.
A recent report about action of bacteria creating protection against inflenza (http://www.nature.com/news/2011/110314/full/news.2011.159.html) contained the following comment: "do bacteria intentionally induce this process in order to protect their hosts from flu infections? Or is the inflammasome non-specifically activated by the bacteria, and one consequence of inflammasome activation just happens to be flu control?" Either way, "it's become clear that our immune system has evolved to act like an interface for microorganisms to send signals to our body".
These comments are reminiscient of Richard Dawkin's comment that "the idea of animals behaving "as if" calculating odds without really doing so is fundamental to an understanding of the whole of sociobiology". The quote above applies this pretence to bacteria.
A far simpler, and more logical explanation is that immune systems evolved to protect organisms from external threats by adapting dynamically to those threats. Immune systems evolved because organisms that lacked systems to protect them from external threats failed to survive.
A major research focus needs to be greater understanding of the effects of trillions of bacteria in our gut. The possibilities from interactions among bacteria types, food types and genotypes overwhelm traditional research approaches, demanding new approaches to research.
www.ideasintuitionandthinking.com
ormondotvos,
Reply | Report Abuse | Link to thisI believe scotsilv's bone was with the use of the word "robust" in describing healthcare IT. His opinion appears to be that HIT apps are not robust. If you investigate further, you will find that he has significant experience in healthcare IT; probably more than you have.
@cramer. I stand by my position that the last thing we need is more pleas for more time. If the apps suck, incentivize them with money.
Reply | Report Abuse | Link to thisHealthcare apps require doctors who use them and report accurately on their efficacy. If that isn't happening, the supervisors need more leverage on doctors, whom I have found to be notably recalcitrant, due to a combination of overwork and a desire to stop the ride on the hamsterwheel, but without stopping the income benefits.
Medicine is no country for old men.
This is something I have given a great deal of thought. I read about a database located in Utah with software driven diagnosis capability. Most likely there are other places as well that contains vast amount of historical medical data. What is the reason this information is not relatively available to all doctors and people in general. What is it with keeping medical information a trade secret and preventing others from access. I see no difference in witch doctor's maintaining their trade secrets and our current medical industry. Doctors diagnosis are in comparison to the saying of a person with more than one watch.
Reply | Report Abuse | Link to thisI suspect the largest strangle hold on doctors is; 1) Mistakes doctors made during their residency resorting from lack of sleep. 2) The code of silence. 3) Law suits. 4) The God syndrome. 5) Placing money above their patients. 6) Doctors hidden mistakes causing harm to their patients. Do people realize working long hours is no different from driving drunk.
Concerning cultural differences: When I spent a year in Germany I discovered that doctors there thought pregnant women should gain three times the weight American physicians recommended. A student of mine from Sri Lanka documented the treatment of the symptoms of schizophrenia in the U.S. and her country, where there was little awareness of psychological analysis. Both treatments seemed to me equally bizarre and (in)effective! Just as Republicans think lowering taxes will cure every problem, so physicians who do not smoke or drink are likely to tell all their patients to quit smoking and stop or limit their alcohol consumption as a matter of course.
Reply | Report Abuse | Link to thisActually, both smoking and drinking in excess are highly comorbid with a vast array of pathologies. This is the primary reason why doctors recommend that patients cut back on these two activities. Further, I suspect you will find many doctors who partake in both activities providing similar advice. In fact, I don't know that there is any evidence to suggest that medical doctors lead healthier lives than their patients.
Reply | Report Abuse | Link to thisIn Australia, my expeience is that there are a large number of incompetent doctors who make little signifiicant effort to keep up to date. It is a lucrative profession and by the age of forty many GPs are in a position to reduce their workload. In becoming part time workers they also lose touch with new developments.
Reply | Report Abuse | Link to thisThen there is simple carelessness and neglect. For example over the Xmas - New Year period, critical pathology indicating a change in my mother's medication sat on a doctor's desk while they were on holiday, and was not acted upon until the second week of January.
The traditional method of selecting for medical training, on purely academic results at high school level, selects a large number of greedy, status seeking, conformists who are totally unsuited to a caring profession. And yes there are a lot of diligent caring professionals who do their absolute best for their patients.
....oh and the only thing worse than falling into the hands of lawyers is falling into the hands of doctors!
Reply | Report Abuse | Link to this"Similarities between Gregory House and the famous fictional detective Sherlock Holmes, created by Sir Arthur Conan Doyle, appear throughout the series. Shore explained that he was always a Holmes fan, and found the character's indifference to his clients unique. The resemblance is evident in House's reliance on inductive reasoning and psychology, even where it might not seem obviously applicable, and his reluctance to accept cases he finds uninteresting. His investigatory method is to eliminate diagnoses logically as they are proved impossible; Holmes used a similar method. Both characters play instruments (House plays the piano, the guitar, and the harmonica; Holmes, the violin) and take drugs (House was addicted to Vicodin; Holmes uses cocaine recreationally). House's relationship with Dr. James Wilson echoes that between Holmes and his confidant, Dr. John Watson." (Wikipedia)
Reply | Report Abuse | Link to thisThink of House's ubiquitous whiteboard. Presented with progressive symptoms, House posts them on his whiteboard for all to see. Usually the patient has relatively few (but fairly specific) symptoms and progressive complications to the 53rd minute of the program, at which time House has his predictable Aha moment and solves the weekly medical mystery.
What's wrong with that picture?
Why are doctors (surgeons in particular) bound to diagnose illness subjectively, seemingly by the seats of their pants? With a comprehensive (even worldwide) database of illness, symptoms, treatments and outcomes, doctors could focus on symptoms, enter them in query form to the database and get immediate, quickly amended and refined diagnoses with distributed probabilities and treatments. Thus, Gregory House and his whiteboard would go away; an audit trail would be made of tests and observations and much of the aimless subjectivity of medical diagnoses that are not up to contemporary snuff would be relieved.
Obama planned to give US healthcare $30 billion or so to computerize patients' medical records. Sounds like money well spent. Furthermore, if that improvement is funded by the government, some provision should be made to open the data to online public query. Part of our problem is that it is virtually impossible now for persons in search of healthcare to discover outcomes and costs of doctors and hospitals before the fact.
Someone here referred to difficulty as "the medical code of silence"...symptomatic of fortified monopolistic practice, in my opinion.
Yet another reason to support comprehensive healthcare reform.
When reading this very well based article, one has the feeling that authors are not practising doctors. The answer to the dilemma of several doctors proposing different therapies for the same disease or patient, that authors solve saying that they can't be all them right, is that probably all doctors are right, as there are very different approaches that lead to the same goal of healing or improvement. Elements not fully addressed by the authors, such as costs and above all, patient preferences must be taken into account. Many years ago, it was known that chinese are slow acetylators, they poorly metabolize drugs such as Isoniazid, used for tuberculosis therapy, and get toxicity from it. The subject become today a full new medical field, pharmacogenomics, where genetic traits of patients are studied to determine which drug is best for them, or which one is probably going to hurt the patient. Modern medicine, at least in developed countries, is moving towards a very brilliant future, in the line of the book entitled "The future shock". Enjoy it, and keep in mind the less favoured ones.
Reply | Report Abuse | Link to thisSorry, the book I tried to refer to was Alvin Toffler's "The third wave". Please accept my appologies
Reply | Report Abuse | Link to thisYour stoopid. That comment benefits no one i guarantee. If you had better character your comment would have much higher quality.
Reply | Report Abuse | Link to thisAs a physician I applaud attempts to improve care through education, standardization, error-control, and improved data availability - all of which MAY be improved through computerization. However, computers must be programmed by people, and often by people without medical knowledge. They are most definitely not a panacea for the problem that "physicians don't know what they are doing" because neither do the programmers. It is fairly absurd to think that anyone is going to "know" the right course of medical treatment to the degree of certainty that is possible in mechanical engineering, for example. Biological systems with literally millions of variables can at best be approached with generalizations and "experience" (i.e. educated guesses). And we can make progress - my subspecialty of neonatal care is vastly better at saving life and preventing morbidity than it was 30 years ago. However, it is not possible to gather enough data to ensure that Baby Smith's premature lung disease should be treated exactly like Baby Jones'. Not because their disease isn't a similar process, but because it occurs in the context of two human beings who are at many levels vastly different.
Reply | Report Abuse | Link to thisAfter 30+ years of practice, I suspect there is much good to be found in "evidence-based" medicine and probably also in computerization. Unfortunately, I also suspect many "best-practice guidelines" lend themselves to a form of regulatory capture. The academics, device makers, and pharmacy companies tend to ratchet up the level of care for all patients regardless of value. I have a patient who has had two heart attacks and a surgery for lung cancer in the last year. Surprisingly, she looks remarkably well. Should I continue to treat her (probably) slow-moving glaucoma? The cost will be perhaps $2000 annually to meet the "best practice standards" for drugs and visits every three months to meet a protocol of field testing, computerized scans, pressure checks and other assessments of her optic nerves. The meds are about 70% of that cost estimate. I don't really think I'm adding much other than another worry to her life, yet stopping treatment is a risky proposition, slightly so for her vision and definitely for me. Does if make a difference if she were poor? Heeding compassionate concerns for "value" even with sound clinical judgement can easily look in hindsight like malpractice. Danger lies on either side of narrowly-defined treatment guidelines and messy realities. Single-system guidelines often neglect global outcomes.
Reply | Report Abuse | Link to thisComputerization is very expensive and will be used by the government mainly to automate record audits, by physicians to try to bullet-proof their documentation. I hate to be cynical, but the "evidence" gained by tracking our every move will probably create a great deal more data for political arguments than for improvements in care. I suppose I could hope for the latter...?
Part of the problem here is the quality of education that physicians receive. Most of their training is in the clinical setting, which is important, but they also need extensive training to be responsible consumers of experimental research. Two years of coursework and two years of clinicals are obviously not enough. The practice of medicine requires a lifelong commitment to learning, in which a physician must keep abreast of current research and findings related to their specialty. Therefore, in order to keep their license to practice medicine, they should be required to attend annual conferences or classes discussing the findings of such research. For if they do not know the current research, how are they to put it into their practices?
Reply | Report Abuse | Link to thisAlso, what system is currently in place to provide regulation and oversight to family practice physicians? Does anyone hold them accountable for anything?
1. Many studies purporting to be scientific, are actually medical studies, done with poor control, often with the excuse that controls for that study are unethical. This issue alone nullifies certain studies.
Reply | Report Abuse | Link to this2. Small samples are another problem with many medical studies. This raises the level of uncertainty.
3. Many scientific studies use animals which are not always fit analogues for human response to chemicals or other treatments. Other animals have differing physiologies and vulnerabilities.
4. Randomization, is, as the author points out, poorly randomized, especially in medical studies. Results of such are highly confounded and no conclusions can be drawn from them. This is a big reason we find conflicting results published across time.
5. experimental bias is documented well enough to show that experiments funded by an entity, either result ins favoring that entity, or the results are written to appear favorable to that supporter. Metastudies have found this bias to be in 90th percentile range! This alone is good reason for government support of testing, and severe oversight.
Drug trials are often weakly designed for these and other reasons. Sufficiently long-term studies are impossible in the present marketing climate of the 20-21st century.
Since placebo effect nears 37% and above in the short term, it would seem that any drugefficacy study would have to significantly differ from that figure. Many drugs are ok'd with effectiveness levels of as little as 40% - not significant unless a sample were huge.
I have found many MDs to be poorly versed in science outside their discipline. The training required leave less than optimum room - time, stress, inclination -for scientific training.
Graduate degrees involve improving broad evaluative abilities, while the sheer memorization/drive/focus required for medical degrees can suppress inquisitive spirit.
A medical degree is often a gauntlet run, rather than part of a lifelong learning process. This is by no means always true.
"Old doctors" are not more predisposed to discontinue learning than young doctors. The problem is individual.
The bacteria themselves evolved to favor commensal, and symbiotic relationships. The ecosystems in guts are themselves immune systems, in that relative stability occurs with multiple overlapping niche occupation, variable nutrient need and sourcing. A stable ecosystem is complex - the more complex, the more able to recover from disturbance.
Reply | Report Abuse | Link to thisImputing intention is merely efficient shorthand for lengthy explanation. Among peers, it is common.
Intention itself is a mental characteristicshared by many complex organisms, and in broader definition can include a cell obtaining or ingesting what it needs, and excretingor avoiding toxic environs or materials.
Even physicists and chemists use intentional language to quickly describe response.
The flaws you highlight in much of today's research....yet another reason why physicians should be trained to be responsible consumers of experimental research. I guarantee that many of today's practicing physicians would not know to look for flaws regarding sample size, randomization, experimenter bias, etc. Therefore, not only do they not keep up to date on research, but they are also unable to weed out the crap from the meaningful results and implications.
Reply | Report Abuse | Link to thisThe best way to learn all of this is to DO. I think that med school curriculum should include courses in experimental design and statistical analysis.....Maybe some do. I just know by experience that some definitely do not. For I would have no idea about experimental design and what to accept as solid research and what to question had I not been involved in behavioral neuroscience research as an undergrad. Many do not have this opportunity, thus a change is needed in the curriculum.
"...Why are so many physicians making inaccurate decisions in their medical practices? It is not because physicians lack competence, sincerity or diligence, but because they must make decisions about tremendously complex problems with very little solid evidence available to back them up..."
Reply | Report Abuse | Link to thisHere's a possible answer to the question above: http://www.scribd.com/jfkusa
Doctors do not know, really, what it means "the BODY"!
"...Why are so many physicians making inaccurate decisions in their medical practices? It is not because physicians lack competence, sincerity or diligence, but because they must make decisions about tremendously complex problems with very little solid evidence available to back them up..."
Reply | Report Abuse | Link to thisHere's a possible answer to the question above: http://www.scribd.com/jfkusa
Doctors do not know, really, what it means "the BODY"!
Thnx for sharing this <a href="http://www.vethekim.net">Veteriner</a> blog post
Reply | Report Abuse | Link to thisAll segments of society suffer from the same two over riding problems, summed up as "tradition" and "belief". We have modern science, but fail to follow the guidelines, because it is new and different from the inherently easier practice of just copying the last guy. We have the mistaken idea that spontaneous genius exists as a "gift from God" or something, where our imagination is allowed to over ride evidence. This is the origin of the phrase; "medicine is an art and a science".
Reply | Report Abuse | Link to thisIn radiography school, the same thing is said of X-ray technology, it is an art and a science. There is no art in radiography. The technologist uses standard positions, measures the patient part and applies recommended exposures. It is all science. The technologists are forbidden by law from inventing new positions and making additional exposures, of their own choice, so what could be constituted as art?
Great harm is created by continuing to teach the idea that medicine is an art and a science. Diagnosis is not an art. diagnosis is careful evaluation of the evidence, more like detective work. Both physicians and technologists need to be taught to follow guidelines that have been properly researched. Only ego can explain the clinging to the idea of art in medicine. I found, as quality control officer of the radiology department that simply asking technologists to measure each patient before setting exposures, was considered and insult to their concept of "artistry" and judgment, because of this implanted idea that radiography is an art. The problem has been so widespread for so long that modern radiographic equipment uses sensors to turn off exposures when sufficient penetration of the part has occurred. There goes the "art"; it has been done by a machine according to mathematical formula, a fixed relationship, not any kind of art.
Instead of catering to the inflated egos of doctors and other health workers, let's give higher concern to patient well-being.
You DO have free will so all you need to do is simply NOT utilize the services of any physician and you will be in good hands then, right?!
Reply | Report Abuse | Link to thisAMEN!
Reply | Report Abuse | Link to thisWhile we have too many technological advancements in Modern Medicine, the cure takes longer, you are sure of the side effects and of course it is costly.
Reply | Report Abuse | Link to thisI am yet to see a Doctor of Modern Times( I mean from late eighties) who checks up your pulse, talks to you on your symptoms and family History.
They start writing prescriptions and order tests, not necessarily in that order
Specialization in Medicine is fine but most of the Doctors seem to be unaware of the other parts of the body.
Nor they seem to be bothered about the side effects of the medicine they prescribe.
Hospitals having become Corporations, the Doctors do not even ask you your case, they have it recorded by some body else and you carry the paper inside.
To check the veracity of my statement please go to a Multi-speciality Hospital.