Thursday, February 11, 2010

Evidence Based Medicine

We like to give lip service to the term evidence based medicine as physicians. It's a hallmark of cutting-edge scientific, modern medicine. Not shooting in the dark with our recommendations, not rigidly following the dogma of the expert's experience, not hoping our theories work out but insisting on PROOF that we're doing more good than harm.

But it goes beyond that.

Evidence based medicine is a way of turning the age old recommendation and paternalistic guidance of the physician into teaching, empowerment. It's rather ironic that as medicine has grown more complicated, we're expecting more and more understanding from our patients. Now patients make decisions after weighing the ups and downs of a medication or test; before patients were compliant with instructions.

And we should praise evidence based medicine; look at what it has saved us from already:

Screening stress treadmill tests which caused more harm from evaluating all the false alarms with heart cath tests (the plastic tube through the groin artery test) than saved lives through early detection

Screening Chest Xrays for catching lung cancer early in smokers (found spots that didn't need to be found AND added radiation which is cancer causing to the smokey mixture in the lung tissue)

Screening CT scans for kidney cancers (found more spots that were never going to spread in the lifetime of the individual than caught and cured genuine deadly cancers)

Screening CT scans for lung cancer (found just as many "cancers" in nonsmokers as smokers, the overwhelming majority never to cause a single symptom)

We learn from our mistakes and abandon harmful practices all the time. But when it comes to screening mammograms, medicine as a culture holds on stubbornly no matter how high the pile of damning evidence grows.

And it's no wonder. To admit that we've done more harm than good with screening mammograms would be admitting that most of the women we labeled as breast cancer survivors were victims of unnecessary treatment. It would also be admitting that the benefits and harms were unclear at the onset of large scale screening in the 80s. Which is an admission that our collective experience with screening mammography has been a large failed experiment.

We live in a society that equates being wrong with failure; we practice medicine with the constant judgment of the "Standard of Care" hovering an inevitable lawsuit away and we devote our lives to curing , relieving suffering and advocating. We have a score card in our head and the evidence tells us that most of the cures, most of the victories were actually harms.

And eventually, admitting screening mammography was a failed experiment without proper consented draws out the conflicts of interest within the wealthy so called advocacy groups such as the American Cancer Society.

Which leads to organizations like DuPont and General Electric (the largest corporation on earth according to Forbes 2009). Companies who have either funded, created and or benefited from the positions and marketing prowess of the ACS.

But more importantly, rejection of screening mammography is a rejection of powerful forces who are hopelessly budgeted to the continuation and expansion of harmful, expensive procedures while minimizing true prevention and treatment.

The health of the largest corporation on earth hinges on screening for breast cancer?

Crazy world.

In other words, I have been wrong and for a decade participated in the promotion of harmful medical practices while gaining financially. I regret my negligence and will strive to prevent the same error from ever happening again as I openly explore what led to my errors.

1 comment:

  1. Evidence-based medicine has morphed into pharma-based medicine and HMO-based medicine. Evidence is based on data from medical journal articles, epidemiology and economics, which relies on randomized clinical trials, which doesn't even require a medical education. Nonphysicians trained in social science, science or even public policy analysis, have judgement over medicine. Where doctors defined the "standard of care," now payers and purchasers of medical services redefine the standards for appropriate medical care, encouraging doctors to act in ways to promote their financial interest when they make medical decisions.

    The use of clinical trials to establish prescribing guidelines for evidence-based medicine is highly criticized because such trials have little relevance for the individual patient in the real world, the individuality and uniqueness of each patient. The problem is not lousy doctors, it's a lousy system. In cancer medicine, the best reform to the system is to totally remove the profit incentive from chemotherapy administration. Take physicians out of the retail pharmacy business and force them to be doctors again.

    When clinically relevant and accepted drugs may have the same efficacy, and a tumor is resistant to one of them, it is within the standard of care to give the drug with the least resistance and/or the drug with the most sensitivity.

    My personal belief is having additional support of drug patient-specific activity as determined by extensive laboratory pre-tests to bolster the clinical justification of the drug(s) chosen, with no economic ties to outside healthcare organizations; recommendations made without financial or scientific prejudice.

    Until the controlled, randomized clinical trial approach has delivered curative results with a high success rate, the choice of physicians to intergrate promising insights and methods remains an essential component to quality cancer care.