“The conflict between evidence-based medicine and individuals is at the core of the struggle to reduce the cost of care. I fear it is intractable and will remain so… We need to talk about the tensions and uncertainty, with respect for each other and with open minds. I’m not sure what solutions are possible but without an ongoing, messy discussion, we won’t find out.”
“In a recent experiment, the average effects of the opioid remifentanil were either doubled or extinguished by manipulating subject expectations; functional magnetic resonance imaging scans showed that regulatory brain mechanisms differed as a function of these expectations. Does this mean that we might double our gas mileage if we wished for it hard enough? Well, no. But people are not machines, and we shouldn’t treat them as such.”
Daniel E. Moerman, Ph.D.
“Patient Centered Medicine” sounds ethical and humane. It almost seems like an obvious thing to strive for, but it is far from universally accepted. Many stakeholders and quite a few opportunists in today’s health care system are working hard to shift power further and further away from the patient-physician decision-making that takes place in the exam room.
In every patient visit there are at least two more parties represented besides the doctor and the patient:
Since the majority of patients are covered by health insurance, the insurance company is always present in any decision that involves money. It would be naïve to expect anything else; that is what happens when someone else pays the tab.
In recent years we have also started seeing “experts” of various kinds judging or prejudicing the medical provider’s performance. Most of the time, these “experts” make recommendations and publish “guidelines” without much authority behind them, since there are often competing guidelines for doctors to choose between. Lately, though, through stronger associations between payors and “experts”, “guidelines”, now re-introduced as “Evidence Based Medicine”, are increasingly used to control what happens in the exam room.
The notion of practicing “Evidence Based Medicine” is not new; doctors study the basic sciences in medical school, read scientific journals and attend continuing education courses to keep up with new developments in their field. What is new is the notion that doctors somehow cannot be trusted to weigh all the available evidence, like other professionals, and sit down with individual patients to discuss how the evidence applies to each unique case.
The “Evidence” seems to have lost its plurality, which is more consistent with the thinking of statisticians and insurance actuaries than with science. The more we learn about diseases and the human body, the more we understand that people are different. Genetics and neurobiology are beginning to explain why treatments that work in some patients may not work in others, and may even be harmful to some.
Jesse Gruman, in her springboard article for Better Health’s Grand Rounds, writes about the inherent conflict between Patient Centered and Evidence Based Medicine in cancer treatment. In each such case, the personal and financial stakes can be enormous.
On July 14, The New England Journal of Medicine published a study comparing inhaled albuterol, the Evidence Based, time-honored treatment for mild asthma attacks, with placebo inhalers, sham acupuncture and doing nothing. Only the albuterol inhalers improved patients’ breathing test performance, but the patients who received placebo inhalers and sham acupuncture experienced the same amount of symptom relief. Only the patients who received nothing were unimproved.
Daniel Moerman, in his editorial, comments on the study:
“For subjective and functional conditions — for example, migraine, schizophrenia, back pain, depression, asthma, post-traumatic stress disorder, neurologic disorders such as Parkinson’s disease, inflammatory bowel disease and many other autoimmune disorders, any condition defined by symptoms, and anything idiopathic — a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician… Usually the control is designed to convince the doctor yet is irrelevant for the patient and patient-centered care. Often the very assumption that there is a correct control simply is not the case… Maybe it is sufficient simply to show that a treatment yields significant improvement for the patients, has reasonable cost, and has no negative effects over the short or long term. This is, after all, the first tenet of medicine: “Do no harm.”
Moerman’s words challenge us practicing physicians and scientists to be prepared to reconsider the purpose and priorities of many of the things we do on a daily basis. His words must be even more unsettling to all the non-clinicians who make their living trying to tell us what to do.