Wednesday, November 11, 2009

Evidence plus intuition equals good health care

When I was in residency, one of my favorite faculty members kept a running list of "medical myths," things that most doctors believed to be true but in fact had been disproven (often long ago) by controlled experiments. Many of these myths were held by surgeons; for example, 1) patients with acute pancreatitis should not receive morphine for pain control because it will only worsen the problem (actually, it doesn't, and the most commonly used alternative, meperidine, provides less relief and more adverse effects) and 2) patients with suspected appendicitis should not receive any pain medication until they've been examined by the surgeon, or the classic abdominal examination signs will be "masked" by the medication (actually, there's no evidence that early pain relief worsens surgical decision-making). The British Medical Journal annually publishes critical reviews of popular medical myths; apropros for the season, the 2007 edition found that Thanksgiving turkey doesn't make you any more sleepy than chicken or beef.

Medical myths are obstacles to health care reform because at best, they waste money, and at worst, they lead hospitals and physicians to provide "care" that is actually harmful. When confronted with evidence that they are doing things to patients that are not supported by scientific studies, many physicians claim that the results of the studies don't apply to their patients - which can occasionally be true, but often isn't, as Newsweek columnist Sharon Begley recently wrote:

Of course, practicing medicine should not be like following a cookbook recipe. If doctors conclude that an individual patient is very different from those in studies that showed a particular treatment to work, they might be justified in treating that patient with something other than the EBM-supported drug or procedure. The trouble is that too many doctors think they have exceptional patients.

To this, I would add that many doctors just consider themselves to be exceptional. Last week, following the publication of a study in the New England Journal of Medicine showing that the older technique of coronary artery bypass surgery (CABG) with a heart-lung machine actually produces superior outcomes than the newer technique of "off pump" CABG, cardiac surgeons who perform the newer (and apparently inferior) technique were quick to tell reporters that the results of this rigorous study didn't apply to them. If you or a relative need any type of heart procedure in the future, I'd advise avoiding those doctors like the plague (or a heart attack).

Good things happen when health care follows the evidence. In last weekend's New York Times Magazine, David Leonhardt described how Intermountain Healthcare, a nonprofit health system serving Utah and southeastern Idaho, has successfully adopted evidence-based protocols for 50 clinical conditions that have resulted in dramatic declines in bad patient outcomes, including deaths. These protocols are continuously assessed and improved, and doctors who don't get with the program (usually those who believe their medical intuition to be superior to EBM) are confronted with data showing that their patients do worse than average. In my mind, the next step in health care reform is to apply this process on a national scale, in order to convince the leaders of other hospitals and health systems (only 1% of whom rate their care quality as "below average") that they're not exceptional, either.