Category: Evidence Based Medicine

In praise of placebos – Pittsburgh Post-Gazette

 

In alternative treatments, patients are told that “it will take time to regain your health.” Granted sufficient cultural authority, chiropractors and other alternative medicine practitioners could dissuade patients from risky and painful medical tests, dependence on addictive drugs and needless surgeries.

This makes what chiropractors do secondary to what they prevent. True natural healing may involve distracting patients with a good story and avoiding medical interference. Spinal manipulation at least gives patients time, reassurance and permission to recover — without a costly back surgery that often has no greater probability of success than time and encouragement. (Of course, alternative medicine can become the new dependence — and the new form of bloated expenditure — as “regaining health” creeps into ongoing treatment for “maintaining health.”)

The greater theme here is that so much of our health and well-being lies in our connection with others. My study found that people receiving care — even if it was sham therapy in a control group — showed greater improvement over those stuck on a waiting list.

The logical conclusion is that we are more resilient and more likely to recover if we have a plausible explanation of why we hurt and when the pain might end, and if we know that someone cares. How many other conditions might also require just patience, community and time to heal?

In praise of placebos – Pittsburgh Post-Gazette

BBC News – Do doctors understand test results?

Don’t cheat!

But it’s not just that doctors and dentists can’t reel off the relevant stats for every treatment option. Even when the information is placed in front of them, Gigerenzer says, they often can’t make sense of it.

In 2006 and 2007 Gigerenzer gave a series of statistics workshops to more than 1,000 practising gynaecologists, and kicked off every session with the same question:

A 50-year-old woman, no symptoms, participates in routine mammography screening. She tests positive, is alarmed, and wants to know from you whether she has breast cancer for certain or what the chances are. Apart from the screening results, you know nothing else about this woman. How many women who test positive actually have breast cancer? What is the best answer?

  • nine in 10
  • eight in 10
  • one in 10
  • one in 100

Gigerenzer then supplied the assembled doctors with some data about Western women of this age to help them answer his question. (His figures were based on US studies from the 1990s, rounded up or down for simplicity – current stats from Britain’s National Health Service are slightly different).

  1. The probability that a woman has breast cancer is 1% ("prevalence")
  2. If a woman has breast cancer, the probability that she tests positive is 90% ("sensitivity")
  3. If a woman does not have breast cancer, the probability that she nevertheless tests positive is 9% ("false alarm rate")

In one session, almost half the group of 160 gynaecologists responded that the woman’s chance of having cancer was nine in 10. Only 21% said that the figure was one in 10 – which is the correct answer. That’s a worse result than if the doctors had been answering at random.

The fact that 90% of women with breast cancer get a positive result from a mammogram doesn’t mean that 90% of women with positive results have breast cancer. The high false alarm rate, combined with the disease’s prevalence of 1%, means that roughly nine out of 10 women with a worrying mammogram don’t actually have breast cancer.

I’ve often argued, when consumer choice and consumer driven health care are brought up as the solution for our health care woes, that doctors don’t even know how to make reasonable decisions so how can we expect lay people to do it?

 

BBC News – Do doctors understand test results?

JAMA Network | JAMA | Views of US Physicians About Controlling Health Care Costs

 

Physicians’ views about health care costs are germane to pending policy reforms.

Objective To assess physicians’ attitudes toward and perceived role in addressing health care costs.

…

Results A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%). Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients’ best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” …

JAMA Network | JAMA | Views of US Physicians About Controlling Health Care Costs

Stunning Healthcare Overture from Bipartisan Group of US Senators – 2007

Healthcare Legislation in This Congress? – Michael Barone (usnews.com)

I followed Ezra Klein’s link to this letter from 10 Senators, 5 Republicans and 5 Democrats, written just two years before President Obama took office! Read it, as it is stunning how far the Republican Choo Choo has gone around the bend.  [Courtesy USNews.com and Michael Barone.]

Now Wyden and nine other senators, five Democrats and five Republicans, have sent the following letter to Bush. Very interesting.

In addition to Wyden, the letter was signed by Republicans Jim DeMint of South Carolina, Robert Bennett of Utah, Trent Lott of Mississippi, Mike Crapo of Idaho, and John Thune of South Dakota, and Democrats Kent Conrad of North Dakota, Ken Salazar of Colorado, Maria Cantwell of Washington, and Herb Kohl of Wisconsin.

The text of the letter follows:

February 13, 2007

The Honorable George W. Bush
1600 Pennsylvania Avenue
Washington, D.C. 20500
Dear Mr. President:

As U.S. Senators of both political parties we would like to work with you and your Administration to fix the American health care system.
Each of us believes our current health system needs to be fixed now. Further delay is unacceptable as costs continue to skyrocket, our population ages, and chronic illness increases. In addition, our businesses are at a severe disadvantage when their competitors in the global market get health care for “free.”
We would like to work with you and your Administration to pass legislation in this Congress that would:
1)Ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage.
2)Modernize Federal tax rules for health coverage. Democratic and Republican economists have convinced us that the current rules disproportionately favor the most affluent, while promoting inefficiency.
3)Create more opportunities and incentives for states to design health solutions for their citizens. Many state officials are working in their state legislatures to develop fresh, creative strategies for improving health care, and we believe any legislation passed in this Congress should not stymie that innovation.
4)Take steps to create a culture of wellness through prevention strategies, rather than perpetuating our current emphasis on sick care. For example, Medicare Part A pays thousands of dollars in hospital expenses, while Medicare Part B provides no incentives for seniors to reduce blood pressure or cholesterol. Employers, families, and all our constituents want emphasis on prevention and wellness.
5)Encourage more cost-effective chronic and compassionate end-of-life care. Studies show that an increase in health care spending does not always mean an increase in quality of outcomes. All Americans should be empowered to make decisions about their end of life care, not be forced into hospice care without other options. We hope to work with you on policies that address these issues.
6)Improve access to information on price and quality of health services. Today, consumers have better accessto information about the price and quality of washing machines than on the price and quality of health services.
We disagree with those who say the Senate is too divided and too polarized to pass comprehensive health care legislation. We disagree with those who believe that this issue should not come up until after the next presidential election. We disagree with those who want to wait when the American people are saying, loud and clear, “We want to fix health care now.”
We look forward to working with you in a bipartisan manner in the days ahead.

Skyrocketing costs! Competetive disadvantage! Universal access to health care! Class warfare! Inefficient US health care! Wellness! Prevention! Cost effectiveness! Compassionate end of life care! Expanding palliative care services! Health care in the US is broken!

Who knew Jim DeMint was a socialist before he was a Tea-Partier?

Why Doesn’t No Mean No? – NYTimes.com

Why Doesn’t No Mean No? – NYTimes.com:

We talk, as a society, of our need to get health care costs under control. Conservatives, in particular, insist that Medicare must be reformed. Here is an enormously expensive drug that largely doesn’t work, has serious side effects and can no longer be marketed as a breast cancer therapy. Yet insurers, including Medicare, will continue to cover it.

If we’re not willing to say no to a drug like Avastin, then what drug will we say no to?

This is the nub of the argument to control health care costs. We have to say no to things that don’t work, whether they have excellent lobbyists or not.

– Sent using Google Toolbar

Squandering Medicare’s Money – NYTimes.com

Squandering Medicare’s Money – NYTimes.com:

“MEDICARE has suddenly taken center stage in American politics, with Democrats now trying to score an advantage from the unpopularity of the Republican plan to overhaul the government health insurance program. Apart from the politics, though, Medicare’s financing challenges are worsening: this month, Medicare’s trustees projected that the insurance program would become insolvent by 2024, five years earlier than previously estimated.

“Much has been said about the growing gap between the program’s spending and revenues — a gap that will widen as baby boomers retire — but little attention has been focused on a problem staring us in the face: Medicare spends a fortune each year on procedures that have no proven benefit and should not be covered. Examples abound:”

Go to the original piece for the rest!

– Sent using Google Toolbar”

Evidence Based Medicine and Reform

This week has been very disappointing, with the USPSTF breast cancer screening guidelines coming out and recieving such an intemperate analysis by virtually everyone with access to a microphone or a camera.

Here is a very thoughtful analysis for those who are interested, but I’m really writing this because of what it says about us as Americans and our love-hate relationship with science.

So, researchers at USPSTF have made an evaluation and recommendations that fly in the face of “common sense.” Common sense in America being that more is always better, whether it be testing or surgery or whatever. You can’t be overtested, there are no downsides to excessive intervention. Except when there are. I will not go into the downsides of overtesting and overdiagnosing, but it really bothers me that we look to science to advance medicine, to make breakthroughs, to guide treatment and yet, we get a recommendation that falls outside of what we “know” to be true, we flip our collective gaskets.

Apparently, sensing opportunity, Glen Beck had on Bernadine Healy, whom I remember becasue she was in a position of responsibilityin Medicine (she was the Director of NIH from 1991-93), and she apparently doesn’t care much for scientific thinking. She trotted out the old saw about prostate cancer survival being better here in America than in the UK because, obviously, the British hate their citizenry.

I have this debunking on the blog here, and it is basically that screening finds things that don’t need treatment, but treating all of these cases as if they are life threatening makes our numbers look good. For a better estimate of how the US really does in saving people for dying from preventable causes, go here to see we have the distinction of being 19th out of 19.

But hearing about Ms. Healy being on glen beck reminded me that I had a letter published in US News (that’s what the editor told me, though I never actually could find the link – ah, well), after she wrote an article praising anecdote above evidence based medicine. HCRenewal has an analysis here, and here is my letter:

To the Editor:

Healy castigates the practice of evidence based medicine in her polemic as if it were anathema to medical science, and, more particularly, to the individual physician’s practice of medicine. Hippocrates knew that “Experience is delusory.” “Experience,” or anecdote, is sometimes helpful in medicine, but often harmful, because we physicians often internalize our experience into hard rules about treating patients. This often leads us down dangerous paths.

Evidence based medicine is long overdue counterweight to this kind of medical practice. EBM, when evidence is available, makes us think hard about our practices: Are we doing this because that’s the way we’ve always done it, or because we have scientific research to back up our decisions? Sadly, it is too often the former, because the evidence is just not there or has not yet been synthesized into a useful form, or, most commonly, not yet reached the physicians “in the trenches.” EBM is not discarding or devaluing physician judgment,” as Healy argues, it is rather an attempt to make our judgment more rational.

I find it astonishing that Healy trumpets the jury awarding damages against a physician who did not order a PSA test based upon the best evidence available to him. Every physician should howl in protest at this outcome. Using this standard, we should all have monthly full body high speed CT scans and massive blood testing to search for every possible disorder that comes to the mind of the physician or the patient. But we do not practice this way because it is, yes, I’ll say it, stupid!

Evidence based medicine is not a “straightjacket”, but a means to an end: providing the best care based on the best scientific evidence we have.

So are we a scientifically based medical community and society, or are we thinking irrationally and letting fear mongers lead us over a cliff?

Don’t answer that.