Why Doctors Hate Science

theodp writes "A 2004 study found some 10 million women lacking a cervix were still getting Pap tests. Only problem is, a Pap test screens for cervical cancer — no cervix, no cancer. With this tale, Newsweek's Sharon Begley makes her case for comparative-effectiveness research (CER), which is receiving $1 billion under the stimulus bill for studies to determine which treatments, including drugs, are more medically sound and cost-effective than others for a given ailment. Physicians, Begley says, must stop treatments that are rooted more in local medical culture than in medical science, embrace practices that have been shown scientifically to be superior to others, and ignore critics who paint CER as government control of doctors' decision-making."

Smart move

[mc1138]

While I am all for people being able to make their own calls and decisions, this sort of research could very well help to streamline more basic medical procedures and help bring to light both new medicines and treatments that might not be able to afford the same advertising as the crap that gets shoved in front of consumers every ten minutes on tv, radio and internet.

Re:Smart move

[Chonnawonga]

Even worse is the advertising that gets shoved in the faces of the doctors! There was another study recently (I'd link to it, but I'm too lazy to go search for it) that found that doctors were making a lot of choices about which drugs to prescribe based on all the advertising and free samples they're regularly bombarded with. Then there was another study that found that drug companies were spending twice as much on marketing as on research. Sadly, family physicians just don't have a whole lot of extra time to be reading up fully on every drug that hits the market. Having a way to distil research and make it more accessible to doctors could go a long way to countering that.

It isn't the doctors in many cases...

[cayenne8]

Hell, it isn't so much the Dr's making the decisions now...for the past decades, we've had the beancounters in HMO's and like dictating what tx the physicians, clinics and hospitals can give.

Couple that with having to do unnecessary tests many times just to CYA to fight off bloodsucking lawyers and malpractice cases....well, that explains a lot of it away.

Politics of health care

[mi]

for the past decades, we've had the beancounters in HMO's and like dictating what tx the physicians, clinics and hospitals can give.

The current evil incarnation of HMOs et al were the result of a misguided and illiberal government policy: let's insure people through their employers. No employer meant either you are too rich for the government to care, or poor enough to be eligible for Medicaid. Self-employed? Sho-sho-shoo, we don't like these people — they are harder to corral.

Losing a job meant losing health-insurance, and switching employer often meant having to switch an insurer, along with the "network" of doctors. Why exactly the two completely unrelated things (job and health insurance) had to be bundled together by government regulation (employers were given a tax-credit for insuring the employees) remains unclear.

Last fall, however, during the elections, two alternatives were put forth. One of them, from Mr. Change, was the old and tried (elsewhere) "single-payer". He said, it is his top choice, but promised not to push for it, although health-related parts [yahoo.com] of the "stimulus" bill suggest the opposite.

The other proposal came from McCain, who wanted to eliminate the employer's tax-credit (the part Obama emphasized during debates) in favor of giving each individual a tax-credit (the part Obama never acknowledged) to be spent on their own health care. This would've created the same kind of market for health insurance as exists for, say, auto, term-life, house, and other insurances. The decoupling of health care from employment would've been much more fare, and the prices would've come down because of genuine competition.

The benefit would've been enormous, because the exelsior ("ever upwards" lat.) health care costs (and the associated evilness of health-insurers) are primarily explained by the fact, that consumers of care aren't the ones paying neither for the care itself, nor even for the insurance. This creates a lot of waste, and leads to — inefficient, but alienating — attempts to control it. Nobody is happy and we may end up with something worse (like government-provided health care), just because it will be different ("Change" is good, right?).

In closing I'd like to offer a real-life example... A doctor gave us a prescription recently for our newborn's acid reflux with the words: "try this, see if it helps her". The prescription was for 30 tablets (30 days). When I got to the pharmacy, I learned, that the 30 tablets cost $190, and that insurance will only cover $120 (for some reason or the other). Here is the point, where different people would think different things:

1. Crap, this is an outrage! When are we going to have free health care — and free medicines? Maybe, Obama will deliver on this.
2. Khm, doctor said: "try it", so let's buy 15 instead of 30 (for half the price) and come for more only if it actually helps.
3. Must be some drug — if prices for medicines were regulated and capped, no one would bother investing into making it.

As you could guess, my thoughts were 2 and 3. But you, likely, know quite a few people, who would think 1 — and, maybe, 2 as well, but angrily.

Re:Politics of health care

[samkass]

The other proposal came from McCain, who wanted to eliminate the employer's tax-credit (the part Obama emphasized during debates) in favor of giving each individual a tax-credit (the part Obama never acknowledged) to be spent on their own health care. This would've created the same kind of market for health insurance as exists for, say, auto, term-life, house, and other insurances. The decoupling of health care from employment would've been much more fare, and the prices would've come down because of genuine competition.

"fare" is right! What kind of negotiating position does someone who needs life-saving care have versus an insurance company? A poor one. The only people who would be able to afford health insurance in that plan are people who don't need it. You'll note that McCain himself didn't seem to eager to buy his own insurance rather than take his employers.

The most efficiently run medical payment service in this country right now is medicare with over 95% efficiency in terms of money going to treatment vs. overhead.

Re:Politics of health care

[cayenne8]

""fare" is right! What kind of negotiating position does someone who needs life-saving care have versus an insurance company? A poor one. The only people who would be able to afford health insurance in that plan are people who don't need it. You'll note that McCain himself didn't seem to eager to buy his own insurance rather than take his employers."

Well, not so much...IF we went back to thinking of medical insurance as INSURANCE. Something to only be there as a safety net, in case of catastrophic medical emergency (ie heart attack, serious injury, cancer...etc).

But for day to day things....routine office visits, and meds....that needs to be planned out in your budget as another part of living within your means.

As a self employed person, I do the high deductible policy ($1200)...and couple that with a Health Savings Account, which for a single person last year...you could load up with $2900 pre-tax. I pay my routine medical needs (including dental and eyesight and supplies) out of this pre-tax money. The HSA earns interest, and when the market is better, can also be invested to grow. The monies remaining in the HSA after retirement can be transfered as retirement $$ to you, much like and IRA.

I find when the Dr. knows I am paying....I generally get about a 15% discount off visits and procedures over what they'd charge insurance.

I wisht they'd expand the HSA program and let you sock a lot more money into it. I'd rather keep this type deal even when I sometimes go back to W2 hourly, or something closer to being an employee some place. But this bastardization we've come to..where you have 'insurance' pay for everything, and co-pays and the like is a bunch of bunk.

Why not let the Feds let US put money away (like we do for rainy days and any other needs) pre-tax....and loosen up insurance for coverage for catastrophic needs.

Why kdawson hates doctors

[Grym]

The current evil incarnation of HMOs et al were the result of a misguided and illiberal government policy: let's insure people through their employers. No employer meant either you are too rich for the government to care, or poor enough to be eligible for Medicaid. Self-employed? Sho-sho-shoo, we don't like these people -- they are harder to corral.

HMOs and federally mandated employer-based healthcare was proposed and signed into law by President Nixon. In fact, there is an infamous tape [youtube.com] of Nixon and his adviser discussing the plan as proposed by Edgar Kaiser of Kaiser Permanente where they blatantly talked about how the emphasis would be on profit (for the HMO) and "providing less care."

What we have today wasn't the result of some master-plan hatched in a secret lair in the lower recesses of an evil University by bleeding heart liberals or whatever you've been told. No, our entire employer based healthcare system is the result of special interest pork legislation written by the industry and pushed upon the public by a Republican administration. It's the DMCA of 1971.

With regard to your child's heartburn, you need to start asserting yourself as a patient and parent. Take an active role in your child's health and specifically ASK your doctor for generic prescriptions. I'm going to go out on a limb and guess that your doctor prescribed Nexium or some other namebrand Proton Pump Inhibitor. The generic, Omeprazole, is available Over-The-Counter, costs a fraction of the price, and works virtually identically. Call your doctor and ask him or her if this is appropriate for your daughter. No doctor I've ever met would mind a call such as this. In fact, I think most would welcome it. Fifteen seconds of his or her time for one potentially satisfied, engaged patient is what you call a clinical no-brainer.

-Grym

Re:Why kdawson hates doctors

[Grym]

You and the GP post are both arguing for 'your team', your political party of choice.

And what team would that be? For the record, I'm an Independent and always have been. I loathe the two parties nearly equally, but I have to admit, I find the Republicans particularly more onerous lately. That doesn't mean I support the Democratic agenda in any way, shape, or form.

Neither of the 'plans' offered are cure alls and neither are perfect. You and the GP are idiots for fighting like you're both behind the only possible solution, when neither one of you have the solution.

You know, normally I love anti-partisan rants like this, but re-read my post. I never advocated for any healthcare reform proposal. All I did was dispute the history behind HMOs as stated by the GP. It was a statement of fact. I never even talked about Obama and his healthcare proposal.

I shouldn't have to qualify any critique of the Republicans with a critique of the Democrats. Buying into the false dichotomy of the two-party system is part of the problem...

-Grym

Why is govt-provided health care worse?

[EWAdams]

I've experienced both systems first-hand -- I'm an American living in Britain. Government-provided health care is FAR superior to what I received in the USA. Easier to get, cheaper, and of equivalent quality. No comparison.

Re:Politics of health care

[Lost Engineer]

There already is a lot of competition driving health care costs down.

Yes but where is the competition to bring the standard of care up? There is some. Some employers will offer multiple health plans, but it's more like Verizon vs. AT&T than figuring out where to eat lunch. The McCain plan was an obvious, painless, and timely way to improve health care for Americans. All Obama has delivered, to this day, is promises.

Re:Politics of health care

[AK Marc]

All Obama has delivered, to this day, is promises.

So that puts him on-par with McCain and ahead of Bush. So where's the problem? If McCain wanted to, he could have submitted legislation to do everything that he promised while running, but hasn't. Does ho not believe in it? Why give up if it is so good for the people?

I'm not defending Obama as much as pointing out that all political attacks on both sides are all meaningless. We never get anything done. Both sides claim they want a stimulus package, yet all votes on it are drawn right on party lines. Both sides claim to be bi-partisan while refusing to compromise, find middle ground, or even consider anything said by the "other side." (the fact that there is an "other side" that is a polar opposite is a devisive tactic designed to win elections and harm the population as a whole between election cycles)

Re:It isn't the doctors in many cases...

[sumdumass]

There are a couple of issues with your complaints.

My GP ordered two MRI's for my back after an injury rather than an X-ray first (the correct standard of care), then an MRI if warranted.

There are some types of injuries to the back that an X-ray will not show. Similarly, there are some back injuries where the initial discovery will (not can but will) mean that the sooner it's effectively treated, the better the chances for recovery and being absent of pain will be. Things like damaged discs won't show up in simple X-rays and the extent of the damage can be permanent if the disc starts healing improperly. Sometimes going for an MRI from the start, depending on the symptoms and stated causes, is the best approach because it will mean the best recovery. I myself suffer from scar tissue in a disc that gives me all sorts of hell and my specialist doctor told me if we caught it in time, it wouldn't be there. Instead, the original doctor treated a ruptured disc as Sciatica for 5 months before referring me to a specialist who then suspected it on the first examination but couldn't prove it without an MRI.

My GP would happily prescribe blood pressure and cholesterol meds without suggesting that, maybe, I should eat better and lose some weight.

In this day and age, you should already know about weight and diet. Your general practitioner will have pamphlets all through his lobby on it, there are numerous PSA on TV and radio about it, you can't hardly go through a checkout line at the market without seeing something on a eating right to lower blood pressure and so on. Depending on the blood pressure at the time, controlling it with meds until a diet is established is probably better then telling you to stop eating salt. BTW, I know several people who having high blood pressure and diet changes were always part of their treatment. And yes, they take pills and went to different doctors.

A orthopedic specialist wanted me to get an MRI to confirm a knee diagnosis. When I mentioned the expense, he suggested an injection of cortisone in the knee the next time it swelled.

This isn't as insidious as you might think. A doctor will want to see if the problem is what they think it is before treating you the wrong way. Ideally, an MRI would have been warranted but if you couldn't afford one, he had to go with other options. Cortisone shots don't fix anything, they just relieves the pain and lubricates the joints while your body heals itself. There could be a number of things that might be wrong in your leg, a torn tendon or ligament won't heal like a muscle will and you won't be able to tell (unless it's completely torn) without an MRI. Sometimes they have to go in and sew the thing back together, sometimes, they can heal on their own. What you got was a savings in payment but not fixed like you should have been.

BTW, there already is a sort of best practices book out there. It lists all the generally accepted treatments for a variety of injuries. It's the same book that the government uses for Medicare/medicade treatment, workers comp claims, and the insurance companies use it for treatments on claims with them. Hell, even the courts use it for allowing compensation for treatments. I forget the name of it, but I have heard it referred many times in the treatment for my back. Your doctor can't get your insurance to pay for anything that isn't listed with your diagnosis and often needs to get authorization. IF it's listed in the book, they can't deny it, if it isn't, you might need a hearing to get approval.

Re:YANAD, hopefully

[commodore64_love]

Well said.

Also this is a gigantic waste of money. They're spending 1 billion dollars so they can eliminate tests and save 100 million dollars in the future. That's bass-backwards. It would be like me spending 10 dollars so I can buy a "1 dollar off" coupon.

Re:Smart move

[Anonymous Coward]

There are a few reasons for what you're talking about. I am a primary care provider myself, a nurse practitioner, and the BIGGEST reason we give out the drugs the reps bring us is because when we give out the drugs we get as samples there is no cost to the patient. You would probably be shocked at how many people can't afford a $4 wal-mart prescription. If this means I give aciphex instead of prilosec I'm going to jump on that pretty quickly.

That said, there was a recent ethics thing where drug reps can't give us pharma schwag (I'll miss getting my viagra clock every year...) anymore, nor can they take us out to dinner at expensive restaurants. *sniffle*

In conclusion, even if you don't have a cervix it makes sense to get a pap of that area, because if you don't have one it probably means that you had all those bits removed for some reason, and the dysplasia or cancer may be present in the areas immediately adjacent to what was removed. Sometimes it doesn't make sense, but sometimes it does.

Re:Smart move

[MagikSlinger]

I had an unfortunate incident of that. I came in with depression/anxiety, and my doctor put me on Paxil. Not because it was the best choice, but because it was the NEWEST one, and the lovely dinner the pharamceutical company paid for had these nice salesmen who told all the doctors how safe and effective with it.

After one night on it, I stopped it and made another appointment with the doctor. To say I had a bad reaction would be an understatement. I'd describe it as extreme anxiety with hot sweats and other wonderful symptoms. Cut to a few years later, I start reading in the news about "unreported" side-effects of Paxil and the drug maker being forced to issue updated clinical notes. Now the warnings [medicinenet.com] list all these things.

The appallingly bad knowledge, especially about new drugs, family doctors have is downright frightening.

If you want to know how my story turned out, I got a referral to a psychiatrist who had many, many years of experience and helped me figure out my problem was a combination of biology, a sleeping disorder I'd recently been diagnosed with and really bad work environment. He helped me figure out which drug worked better for me (one that was new, but was relatively less marketed), talked me through how to make the appropriate changes in my thinking and lifestyle to survive bad times and then after the appropriate monitoring time, sent me on my way, and I've been overall pretty good.

The lesson here is our doctors need real medical knowledge to draw on--not just what the marketers and sales people tell them. Family doctors are usually over worked trying to pay the office rent, the receptionist, the malpractice insurance, etc. And they don't have the time or energy to keep learning anymore, and what they do have time for is usually not of high quality to begin with.

I for one am looking forward to this. It doesn't just benefit America--it could benefit everybody.

Re:Smart move

[Stanislav_J]

The appallingly bad knowledge, especially about new drugs, family doctors have is downright frightening.

All the points being made here are very pertinent, but one factor I have been dealing with (handling my elderly mother's medical care as she is no longer capable of keeping track of things) is that doctors today just have too heavy of a workload. They are juggling so many patients that they cannot possibly devote the time they really need to every individual case. The tendency is to just diagnose and order tests/prescribe drugs based on the most common knee-jerk diagnosis that comes to mind. The House M.D. depiction of a group of doctors having the time to sit around and debate diagnoses with intricate knowledge of every exotic possibility and with ready knowledge of all the latest medical research simply does not happen in most hospitals.

Example: for over two decades, my mother has dealt with achalasia, a swallowing disorder. It is not a common problem, but certainly not some exotic rare disease that no one has heard of. She does have a very capable gastroenterologist, and the problem is currently under control, but it does rear its ugly head now and then. When my mother has been hospitalized and treated for other problems, the achalsia is still a factor as it affects her diet and eating schedule. You would be amazed at the number of attending physicians to whom I have had to explain and define what achalsia is and how it should be handled. Different doctors will all come and go in the course of her stay, none of whom seem to talk to each other at all, or have any inclination to inquire of her gastro doc about the problem, and all of them skeptical at best and disdainful at most of this "layman" son of hers trying to tell them how to do their job. When the achalasia begins to manifest (usually because they ignore or are clueless about the standard recommendations for diet), they keep automatically attributing it to nausea or reflux or some other unrelated condition and try to treat her for that. I can't sit in her room 24/7 waiting to intercept any random new doctor that happens to breeze in at odd times for one of their brief drive-by visits to "educate" them about achalasia (and somehow this information either never gets into her chart, or gets overlooked by these doctors in their overworked haste), so she ends up getting unnecessary treatment for problems she doesn't have. And this is not in some hellhole of a hospital -- this is in the highest-rated, most modern facility in our metro area.

Much as I would like to see some form of universal health care soon, this phenomenon will just be exacerbated by suddenly adding 30 or 40 million new formerly uninsured patients into the system. Doctors already do not have the time to give each patient the time and care they need. Unless they train or import a whole lot of new medical talent quickly, it's just going to jam up the system even more, and there will be an even greater tendency for doctors to make diagnoses and treatment decisions "on the fly" as they breeze through on their way to their next patient.

Re:Smart move

[fuzzyfuzzyfungus]

In addition, the dreaded "rationing" of healthcare is already here, brought to you by the private sector. I work, I have insurance, I pay my premiums; but the insurance company, obviously, makes more money when they deny a claim than when they pay it. A system where procedures are paid or denied based on their expected benefit, as established by actual research, would be a considerable improvement.

In reality, "choice" in medicine is already an illusion for virtually everybody. Unless you can absorb arbitrarily high out-of-pocket expenses, or have extraordinarily generous insurance coverage, your medical choices are already circumscribed by what you can afford, or convince your insurer to pay for. Better data would, hopefully, more closely align people's options with what is actually effective, and increase overall quality.

Re:Smart move

[wellingj]

I see where you are coming from, but I still can't agree that people should eat food and drive cars that they can't afford. I don't to see how health care should be any different.

I think the whole problem there stems from how health insurance morphed to health care. If you want to go see a doctor every year, pay for it. If you get run over by a truck, that's what insurance is for. Insurance is for the unforseable, not the routine. The problem is the line that has to be drawn, and it becomes a pretty grey area, so it's ended up that the insurance company is expected to pay for everything, which of course drives up the cost.

Wondered off on a tangent there... oops.

Re:

[IamGarageGuy 2]

I don't think you wandered off topic, I think you are directly ontarget.

Re:Smart move

[causality]

I see where you are coming from, but I still can't agree that people should eat food and drive cars that they can't afford. I don't to see how health care should be any different. I think the whole problem there stems from how health insurance morphed to health care. If you want to go see a doctor every year, pay for it. If you get run over by a truck, that's what insurance is for. Insurance is for the unforseable, not the routine. The problem is the line that has to be drawn, and it becomes a pretty grey area, so it's ended up that the insurance company is expected to pay for everything, which of course drives up the cost. Wondered off on a tangent there... oops.

Indeed. I can't remember where I heard this, but this is an explanation I've heard: if car insurance worked like health insurance, then every time you put gas in your tank or get an oil change or replace the tires you would file a new claim.

Re:Smart move

[shermo]

Don't give them ideas.

Re:Smart move

[CodeBuster]

MOD THIS THREAD UP PLEASE.

The parent and grandparent are EXACTLY right. The problem with health insurance is that it pays a little bit on everything whereas every other type of insurance on the market: flood, earthquake, fire, auto, etc...is all designed to protect from unforeseen and large expenses that are infrequent or unlikely, but can be very expensive when they do happen. That is what insurance is all about. Do you insure your house against the cost of mowing the lawn? Do you, as the grandparent suggests, split the cost of an oil change or a fill up with your auto insurance company as a "co-pay"? Certainly not, so why then should health insurance be peculiar among all other types? Why can't people save enough money or alter their spending so that they can simply pay for routine care and expenses out of their own pocket as they do for other necessary things in their lives? IMHO, the burden is on the socialized medicine people to explain why health insurance is UNIQUE among all other types of insurance and cannot be left in the hands of private insurance and instead must be provided by the government making regular third-party (i.e. the worst and least efficient kind) payments on routine citizen needs. After all, if the government was or is so efficient at providing health care then why not have them provide other things too like cars, vacations, computers, designer clothing, and everything else that people want.

If people really want to learn about How To Cure Health Care [hoover.org] then they should read the linked article.

Re:Smart move

[ahabswhale]

Sorry but you are massively uninformed. There are different kinds of health insurance just like there's different kinds of auto and disability insurance. What you are talking about is a "major medical" policy that only kicks in when your costs exceed ~$2k. This is the exact kind of policy I have. Why do I have this kind of policy? Because to get a policy that starts at $0 would cost me over a $1k a month. So, these policies already exist and they are already VERY common. The fact that you and the parent poster don't know about them is utterly fucking shocking to me. Even with major medical, I still have to pay over $200 a month for health insurance just for myself (non-smoker, non-obese).

The bottom line is that the cost of health care has skyrocketed compared to average income. It becomes less and less affordable and is becoming a greater and greater burden on the economy. In fact, the idiots that perpetuate the system we have today are driving us into socialized medicine (their worst fear) just because there will be no other way to deal with the costs. Frankly, I can't wait just so I can laugh my fucking ass off. Most doctors fucking suck anyway. Like everything else, 90% of them are worthless. Too bad you don't have time to shop around while you're in the middle of a heart attack.

"After all, if the government was or is so efficient at providing health care then why not have them provide other things too like cars, vacations, computers, designer clothing, and everything else that people want."

You must be fucking kidding me. It would be impossible for even the government to be less efficient than what we have today. Socialized systems in other western countries are far more efficient. We spend TWICE what England and Canada do per capita on health care.

Seriously, you need to actually READ about this stuff before you spout your mouth off. You have no idea what you're talking about.

Re:Smart move

[CodeBuster]

Just because I was talking about a particular aspect of health insurance, one that is common in America, doesn't mean that that is the only type available. You should not interpret the absence of a particular topic in health insurance in this thread as evidence that we don't know about it. I have a high deductible health plan with a health savings account myself (although my deductible is somewhat higher than 2k and I pay a bit less than you do per month every three months or quarterly). However, we are in the EXTREME minority of Americans with health care coverage. Most Americans, those who have coverage anyway, select family HMO plans through their employer with effectively much lower deductibles, although it is not an apples and apples comparison because the HMO plans are structured differently with no lifetime maximums in exchange for more constrained care and escalation choices and procedures.

The bottom line is that the cost of health care has skyrocketed compared to average income. It becomes less and less affordable and is becoming a greater and greater burden on the economy.

Care that in many cases wasn't available for most of the previous century. If you want 3d computer assisted MRIs and other fancy tests and cutting edge drugs to treat your condition or extend your lifespan then you are going to have to pay for them. I have no problem paying for basic health care and if people are stupid enough to go to the emergency room instead of calling their doctor or going to an urgent care clinic (the kind that are open all night and can do most things up to and including minor surgeries for reasonable prices) then they have nobody but themselves to blame. Emergency rooms are for life threatening emergencies most other needs can either wait until morning or you could go to urgent care clinic instead.

You must be fucking kidding me. It would be impossible for even the government to be less efficient than what we have today. Socialized systems in other western countries are far more efficient. We spend TWICE what England and Canada do per capita on health care.

In a manner of speaking you are right, government provided single payer health care is less expensive than the present US system (which almost nobody likes for different reasons). HOWEVER, the single payer system achieves these lower costs with some combination of higher taxes for everyone (taxing is a whole different topic, but suffice it to say that it never works to single out a single group and just tax them without effecting anything or anyone else in the economy) OR rationing of care or both. There is no free lunch, and costs can take on many forms not just money out of pocket. For example, there could be longer lines, or unavailable drugs (like those cancer drugs that NHS refused to pay for in England), or other general economic costs of higher taxes necessary to support the single payer government healthcare system. I would like to go in the opposite direction, towards private pay for everything except expensive life saving care which would be covered as private insurance covers many other risks in our lives. We both agree that the US health care system is broken, but that is not really a revelation nor is it particularly controversial. Everyone knows its broken. Your mistake was to assume that because I don't want government provided single payer health care that I was in favor of the status quo, as if there were only ever two choices: exactly what we have right now OR single payer.

Like everything else, 90% of them are worthless. Too bad you don't have time to shop around while you're in the middle of a heart attack.

Don't know where you have been going, but I suggest that you find a new primary care physician if you are so dissatisfied. The heat attack isn't what I am talking about. If you have a heart attack then the paramedics are probably going to send you to the emergency room anyway if they cannot get you s

Re:Smart move

[Saffaya]

In France, we actually have a dual system.
Public hospitals and private clinics.
Everyone is covered and can go to the hospital. 'The rich' as you qualify them, will go to the clinic and thus pay more, getting things such as a personal room instead of a shared one in the public hospital.
Doctors can get the money from working at the clinic because they also have to work part-time at the hospital.
No 'bribing' involved. Just some common sense and both parties are satisfied.

Re:Smart move

[Estanislao Martínez]

I think the whole problem there stems from how health insurance morphed to health care. If you want to go see a doctor every year, pay for it. If you get run over by a truck, that's what insurance is for. Insurance is for the unforseable, not the routine. The problem is the line that has to be drawn, and it becomes a pretty grey area, so it's ended up that the insurance company is expected to pay for everything, which of course drives up the cost.

The problem with what you're saying is that the sort of routine care you say insurance shouldn't cover actually doesn't cost much to provide. Health care expenditures are really one of those 80/20 phenomena: the vast majority of the cost is spent on the health care of a small number of people.

By making people pay for it out of pocket, all you do is disincentivize routine care (which is cheap to provide). You don't put a dent on the major sources of health costs, and what's worse, you prevent people from getting treated early on, while it's still relatively cheap to do so.

Re:Smart move

[CodeBuster]

I have a health savings account [wikipedia.org] and high deductible insurance plan. I pay out of pocket for all routine expenses such as doctor visits and prescriptions with the exception of one physical which I get free per year and of course high costs that exceed the deductible (i.e. I get run over by a bus and end up hospitalized for major surgery). I do not avoid routine care and my doctor loves seeing me because he knows that he will not have to bill insurance and wait six months for his money, I simply pay him out of the money which I have saved in my health savings account. Why would you avoid routine care when you have purposefully and diligently saved money ahead of time in a tax advantaged savings account specifically to pay for routine health care expenses? I think the answer is that you wouldn't. Now, is this plan for everyone? No, probably not everyone, but for many ordinary Americans this type of plan could work and work well, especially because it incentives people to seek out good quality routine medical care at reasonable prices since they are paying out of their own pocket.

Malpractice and markets

[copponex]

The problem is that the market has come up with an awful solution to medical liability, which is pitting malpractice insurance against health insurance. Much of the cost of health care can be traced back to either. The other source of cost is that health care is sold as any other product on the free market, which is unfortunately very stupid. Deregulation of health care has led to the closure of hundreds of hospitals around the country, and pushed the costs out of the reach of much of the population. This is actually based on market principle, since the question moved from how much it costs to provide adequate health care, to how much people are willing to pay for it. Of course the upper sector of society is loving life with 3d pictures of their unborn child and access to obscure specialists at the drop of the hat, while the rest of the population struggles to pay for pills and basic care.

Now you have people dropping dead of overdoses and mixed prescriptions since the doctor is motivated to treat instead of heal, and billions of dollars are invested in figuring out how to sustain erections instead of preventing cancer. Hopefully the current economic situation will provide enough pressure to put an end to the ridiculous and unfounded belief that the market works for everything. Health care is no different than any other bit of infrastructure. You pay taxes and share risks for the benefit of the whole population.

Re:Malpractice and markets

[GNT]

What f'ing deregulation? YOU DO NOT HAVE A FREE MARKET IN HEALTHCARE. YOU HAVE the MOST regulated market short of universal useless healthcare.

Understand this -- there's no moore law associated with healthcare. NOthing has f'ing changed in 20 years since I first practiced in any significant way.

Cancer survival is measured in 5-year survival patterns and the approval process for a treatment runs up 15 years. Thank you FDA regs. Give me a break. You have no understanding whatsoever of economics in general and healthcare in particular.

This is the end of the road of the inflation that started with Medicaid and Medicare in the 60's.

Re:Smart move

[FrankieBaby1986]

I thought insurance companies helped pay for regular checkups and the like because it helped prevent worse illnesses that would potentially be much more costly?

Re:Smart move

[evilviper]

If you want to go see a doctor every year, pay for it. If you get run over by a truck, that's what insurance is for.

Unfortunately, that is the current practice with health care, and we know what that leads to... Emergency rooms with 4 hour wait times....

It's a bit like saying, if you want to change your oil every 6 months, you should pay for it, your warranty is only for when your car has mechanical problems.

In both cases, if you skip the preventative step, you will end up having to go with the corrective step, which costs vastly, vastly more.

I've often thought that the most inexpensive health insurance, would be the one that REQUIRES you to get a full annual check-up, and accept early preventative care for any conditions found, or else you forfeit your insurance coverage for anything that could have been found and corrected earlier, at much less expense.

As an added bonus, more people would simply be healthier, live longer, and miss less work, all resulting in more money, for you (the health insurance provider).

Re:Smart move

[bluephone]

I don't to see how health care should be any different.

Because I can live without $50 steaks and $100,000 cars. I for one would be dead without a simple medication. I had a medical emergency last year that is relatively simple to perform by a surgeon, took all of 45 minutes under the knife, but I'd have DIED without it. That's why it should be different.

Re:Smart move

[Daniel Dvorkin]

It should be different to keep you alive? What's so special about you that I should have to pay for that?

Well, for one thing, he's a decent human being, which you've just shown pretty clearly that you're not.

Re:Smart move

[Anonymous Coward]

As much as I never really wanted to admit it, I'm beginning to think Durkheim was right.

Yes, it is your responsibility. Not to keep people alive as in your straw-man example, but to balance the needs of your fellow man in your family, your community, your society, etc., against your own desires. That's part of being a social critter. It would be great if it could happen voluntarily, but the logistics of making that happen are far beyond most people's capabilities given the size of modern cultures and the needs of their people.

Don't like it? OK, fine. Go live off the grid. But not before you pay us all back with interest for providing you with a stable social environment, an education, and keeping every random criminal and asshole from doing whatever they want to you. Oh, and good luck with your property rights, since those are an imaginary abstraction made real by the consensual agreement of society. Maybe you better stockpile some guns.

Or, if you'd care to be more reasonable, you can admit that you do have obligations, and it simply becomes a matter of debating and deciding the degree of them.

Re:Smart move

[twostix]

How strange,

In your country if you're accused of a crime you consider it a natural right to have access to a free lawyer and access to free legal advice is enshrined in the highest law of the land. The spirit of socialism at its finest! But oddly there's no "socialism" conflict in that area, even from the "libertarians".

But when it comes to the right to some basic level of healthcare, no go. If you're poor you and your children can suffer.

It's an interesting paradox actually, because generally the poor commit more crime. So people are happy to fund legal representation for lower class criminals. But are definitely not happy to help fund a basic level of health care for themselves. Which is somewhat odd as the vast majority of people will be affected by health issues in their life, not criminal courts. And the costs associated with the two are about the same.

A strange but interesting culture.

(Yes I'm aware of the low quality of public defenders - due to a lack of funding more than anything. But it's better than nothing, just like public hospitals)

Re:Smart move

[dokebi]

You are seriously misinformed. There are two important things wrong with what you're saying.

First, the cost of providing emergency care for accidents isn't something that can be reduced, period. What we can do to reduce health care cost is to increase participation in early detection and treatment of disease, which is *FAAAR* more effective (and cheaper) than treatment later on. It's like a city providing free needle exchanges, because that's are far cheaper than treating someone who contracts HIV or some other horrible disease.

Of course, US health care doesn't run on logic, but rather puritan morals and vague capitalist ideology. The most effective way to prevent teen pregnancy, as determined empirically, is early sex education and free condoms, not home schooling and regular church attendance. But we can't use the most effective method.

Secondly, health care is something that people need throughout their lives. As our population gets older, it's not "insurance" for accidents, but rather an on-going part of their care. Which means there is a continuous, fixed cost that must be paid to take care of someone. Therefore, an "insurance" scheme, where risk/profit is calculated to determine premiums doesn't really work. It's much better to spread the risk to the whole population, and have full benefits for everyone.

The reason health care system in the US is so broken is because it's dominated by interest groups that want a continuous supply of "sick" but rich people. Think of the drug and insurance companies, the plastic surgeons and viagra peddlers. Nobody is really interested in the well-being of the people, and those who should--the citizens of this country--can only imagine a world they see in commercials made by drug and insurance companies. Sad indeed.

Re:Smart move

[Eivind]

There's a difference between healthcare and car-ownership.

If someone, trough bad-luck, bad-planning, silly-choices or other circumstances end up not owning a car, we as a society are generally willing to say: "So walk then, or take the bus."

Not so if someone trough bad luck, bad planning, silly choices or other circumstances end up broke, uninsured and with cancer. We -don't- typically say; "so do without treatment, then."

Re:Smart move

[TapeCutter]

The problem with your "common-sense" categorization of who does and doesn't deserve health care is the same as the problem you have now. An army of pen pushers is needed to run each patient through your moral checklists and hoops to look for any reason they can think of to exclude them.

Here in Australia we have a bipartisan UNIVERAL system that costs 1.5% of your taxable income and is supported by 80+% of the population. If someone needs a tripple bypass because they have sat on their arse for a few decades smoking and stuffing their face with pizza and coke they get one. If they go to the UK or any other country with a reciprocal arrangement and have a heart attack, they are also treated for "free". But guess what, my 1.5% not only pays for much better medical outcomes than the US but also pays for preventative programs to educate these slobs and a prescription benifits scheme that means NOBODY pays more than $1200/yr for medicines.

Add it up, compare 1.5% of your taxable income to how much would it cost you to insure a single income family of four (or even just a single person) to such a level, is it even possible to buy insurance with no loop holes for the insurance company to renege? When you figure that out and find out just how much you are being ripped-off you may want to look into who is pocketing your hard earned cash.

Please note I have not claimed the Aussie system is perfect, far from it. My point is that the irrational belief that UHC somehow equates to rabid socialisim that showers the "irresponsible" with money has lead the US down the path of an ever more complex system of self-delusional, penny-pinching accounting that seems designed to enrich those who prey on the weak and send seriously ill people bankrupt or worse. In other words the fear of being ripped off is the very thing that enables your current system to rip you off.

paps with no cervixes

[UltimApe]

I bet next they give mandatory prostate exams to women too!

Re:paps with no cervixes

[fuzzyfuzzyfungus]

Substantially less useful; but not entirely useless. Breast Cancer in males is uncommon; but not unheard of [cancer.org].

The assumption here

[popo]

the assumption here is that wasteful procedures are due to the profit motives of physicians.

anyone who knows anything about health-care will tell you that the primary cause of most non-cost-effective procedures is fear of legal consequences.

want cheaper healthcare? reform the legal system and get the hmo's out of the game.

Re:The assumption here

[db32]

This isn't entirely true, but it isn't exactly off the mark either. There are simply a stupid number of factors involved here that allow nonsense like this to happen. Insurance companies will frequently pull garbage like "we won't pay for X unless Y has already been done". So then doctors are forced into doing Y before doing X so that the patient doesn't get saddled with an insane bill. Also, before anyone here goes "well the doctor could just not charge" I will point out that these things are RARELY interelated. Doctors don't generally do any of the work themselves. You go to the family doctor for joint pain for example. He says go get an X-ray. Typically only specialists will have their own x-ray equipment (podiatrist/orthopedics/etc). So...either you get refered to a hospital or specialist and go get your x-ray. Bill #2 is now generated. So then that x-ray gets sent off to a radiologist who reads the x-ray into a dictation machine. Bill #3 is generated. Now, as an expense somewhere in bill #2 or #3 is going to be the cost of some transcriptionist group taking that dictation and typing it up. THEN! If you have to fix that joint surgically you go to a hospital...now you are paying an anesthesiologist (who is typically his own practice rather than a hospital employee), you are paying the hospital for your time in their OR and Recovery and supplies used, you are paying a surgeon (who may or may not be working for whoever did your x-rays). Now, at each stage of this process the insurance company gets to dictate terms of what will and won't be paid for. You are still dealing with the profit motivation of the various doctors in that chain (hey, not all of them are good docs, most are, but there are always assholes in every field) and you are dealing with the stupid lawsuits. People have managed to turn honest mistakes into malpractice which I think is fucking insane. Doctors should be held to high standards, but when you say they can't make a mistake without losing their ass the costs of healthcare goes through the f'ing roof. If they remove a lung when you were supposed to be getting a kidney removed...malpractice. If you come out with brain damage after a brain surgery...unless they were just running around with a blender in your head this is just one of the risks of having brain surgery....not fucking malpractice.

All of this doesn't even begin to cover all of the lobbying that the insurance companies and pharma companies do to rig the game in their favor. Everyone bitches about these evil "socalists" trying to screw up medical services, but the real issue is that the die hard capitalists have already fucked it all the hell up in their favor and they are scared to death of losing the kickbacks. (Disclaimer: Go talk to someone in the military about that whole free government provided healthcare...you get what you pay for...)

VA - Pretty Good

[meehawl]

Go talk to someone in the military about that whole free government provided healthcare...you get what you pay for...

I agree that the VA is underfunded relative to its size and patient population but, given its funding limitations, it's actually the best performing health system in the US [www.cmaj.ca] when measured [annals.org] objectively [jamia.org] in terms of patient outcomes [washingtonpost.com].

Re:The assumption here

[davolfman]

The criminal justice system?

Re:

[wellingj]

Don't forget the Hippocratic Oath [wikipedia.org].

Re:The assumption here

[Lurkingrue]

I call shenanigans. When *I* listen to my patients' hearts, I'm listening for new or changed murmurs, irregularity in the rate, bounding of pulses -- and you're taught to do things systematically, and for a reason. Insurance companies give us about 15 minutes per patient if we want to be able to keep our head over water, so if you think anyone wastes time with useless mumbo-jumbo, you're way off-base. Anyway, you don't diagnose a "heart attack" with your stethoscope.

While a bit alarmist...

[blahplusplus]

... as the title of this entry suggest. Not all doctors are created equal, and lets get this straight - all human beings, no matter how educated are very fallible and human.

I had one young doctor think I should have my moles checked out that "looked cancerous" and another doctor whom I'm also freinds with that tells me "that doctor is full of shit". I also had my GP (general practitioner) suggest I had a part of my foot cut off after a series of infections after many an ingrown nail, needless to say I rejected his suggestion and did the work on the foot myself and still have everything all intact and normal as ever.

Just because someone suggests something who is in a position of recognized credentialed authority, does not mean it is a license to take their judgments and advice without scrutiny and a grain of salt.

Knowing how to do this and when is the hard part, but this is something that only people who've lived long enough and have the wherewithal to gain by experience - mankind is extremely fallible. Therefore critical skepticism must be employed when decisions can have significant consequences.

It's easy for experts to suggest something to someone else when they don't have to bear the risk and consequences of going through with it.

I'm torn on this

[DesScorp]

While I like the idea of reinforcing what works and discouraging what doesn't, the fact is, this is a federal study, and likely the well-intentioned results will be some government panel or body controlling what doctors can and cannot do, regardless of the patient's circumstances, all in the name of "science" and "efficiency". They may well make some things better. But they'll inevitably make more things worse.

I want to aid in better treatments, but I can also easily see some overreaching federal agency micromanaging physicians. Sorry, but find me one federal agency that never tried to expand their power exponentially, often in the name of "the public good".

Re:

[SecurityGuy]

find me one federal agency that never tried to expand their power exponentially, often in the name of "the public good".

The IRS. At least, they don't claim it's for the public good. :P

they already are pretty constrained

[Trepidity]

The vast majority of procedures are highly constrained by insurance rules: either the government in the case of Medicare, or private industry in the case of various HMOs and insurance plans, have complex rules about what must be done in what order to get reimbursement. Doctors already have to follow that, so it'd at least be an improvement if those rules had some basis in scientific evidence indicating what treatments really are better.

Re:

[TubeSteak]

While I like the idea of reinforcing what works and discouraging what doesn't, the fact is, this is a federal study, and likely the well-intentioned results will be some government panel or body controlling what doctors can and cannot do, regardless of the patient's circumstances, all in the name of "science" and "efficiency".

I think you're confusing "federal studies" with "federally funded studies".
The reality is that most trials are done by pharmaceutical companies and not impartial non-government organizations.

You can call the status quo a success, if you want the winners to be big pharma's profit margin. Unfortunately, big pharma has one goal: to get the next blockbuster drug (or variation of a previous one) approved by the FDA. Personally, I can't help but observe that the 'free' market has obviously failed "we the people"

Mis-education courtesy of Big Pharma

[macraig]

Why do you folks think Big Pharma is so successful? One of the prongs of their attack on medical knowledge (and ultimately research also) is mis-education and indoctrination of physicians themselves, through both subtle whispering in their ears as well as brute-force constant bombardment. The knowledge of physicians is pretty much under attack from the day they toss that cap in the air, if not sooner.

BTW, I've heard from a family member who is a Kaiser HMO patient that Kaiser does not allow Big Pharma reps direct access to its staff phyicians, and instead funnels them to some sort of departmental liaison; if that's true, that is certainly one good thing that an HMO is doing.

Evidence based medicine is extremely frustrating

[neoshmengi]

I practice evidence based medicine as much as possible. The trouble is that patients have a very hard time understanding it, let alone appreciating it.

I don't give antibiotics for colds, but those patients often go see other doctors to get their antibiotics. When they get their inappropriate prescription, ironically I come across as a bad doctor for not prescribing it in the first place.

When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it. Parents hate that.

I have a cranky baby at home. My friends asked me why I don't use Oval. I told them that there is evidence that it doesn't work. They stared at me like I had three heads. After all, they tried it and it worked for them!

People come in with back pain. My job is to rule out the dangerous causes, and once that's done give them some analgesia and tell them to weight a few weeks for it to improve. Any serious pathology will reveal itself over time if there are no red flags during the initial history and physical. Patients hate that. They want the xray. So they go to their chiropractor who orders a bunch of xrays (placebo 'tests' are very therapeutic to patients actually). "Well, your xray looks fine!"

EBM is hard on the practitioners. The old school of medicine is to say, "This is what you have and this is what you need to do to fix it."

Now we say, "It's likely that you have this, although I can't say for certain. Here are the pros and cons of the treatments. Now what would you like to do?"
Very dissatisfying to a lot of patients.

Everyone wants all the scans and tests even when it doesn't make sense, because they all know the guy who was told that his problem wasn't serious and it turned out to be cancer etc.

The previous party line was that all diabetics should be on aspirin to decrease their chances of having a heart attack. A recent study came out showing very little evidence for primary prevention of heart attacks with aspirin. What to do now? How to integrate every little bit of often conflicting evidence into clinical practice? It's very hard to stay up to date, let alone sift the wheat from the chaffe.

EBM is the gold standard of how we should practice medicine. Yet it is immensely frustrating to put into actual practice.

Re:Evidence based medicine is extremely frustratin

[KeithJM]

When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it.

Have you considered that, although it's no better than placebo, it might be better than nothing? Saying it's no better than placebo doesn't actually mean that they won't see a difference if you don't prescribe anything. It's why they use placebos in trials.

Re:Evidence based medicine is extremely frustratin

[neoshmengi]

When people bring their kids in to get some gravol for their viral gastroenteritis, I tell them that it has been shown to be no better than placebo, so I don't offer it.

Have you considered that, although it's no better than placebo, it might be better than nothing? Saying it's no better than placebo doesn't actually mean that they won't see a difference if you don't prescribe anything. It's why they use placebos in trials.

I have considered it. I also consider the fact that every medicine I prescribe carries risks, even if those risks are low. If I don't know whether the risk outweigh the benefits, I don't prescribe, particularly for 'nuisance' illnesses.

I know many physicians who prescribe placebo treatments and tests. I have trouble doing this even though patients find it very satisfying. What I sometimes do instead is tell people what the evidence is and let them decide. I struggle with the ethics of prescribing a placebo.

Re:Evidence based medicine is extremely frustratin

[Nightspirit]

Stronger dose placebos cost more:
http://www.walgreens.com/library/finddrug/druginfo.jsp?pdid=1088&particularDrug=Cebocap [walgreens.com]

Cebocap #3 (a prescription placebo) costs more than Cebocap #1.

This is right out of Tom Daschle's book

[ducomputergeek]

http://www.amazon.com/Critical-What-About-Health-Care-Crisis/dp/0312383010/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1235966206&sr=8-1 [amazon.com]

And modeled on the UK system where a review board develops a formula the determines if the cost-benefit is worth it or not.

Sounds all good and all, but basically this is what HMO's try to do now.

Only difference I can tell is that the government will be the ones telling you what treatments you can/cannot get instead of the HMO's.

Re:This is right out of Tom Daschle's book

[ColdWetDog]

Sounds all good and all, but basically this is what HMO's try to do now.

Not exactly. Insurance companies historically do not try to make the difficult judgment of how effective a particular procedure or test has to be, or whether one procedure is better than another. All they really want to do is to limit their costs. If they can find some supporting evidence that backs up not paying something, all the better. They are not set up to be, and cannot ever hope to be, "honest brokers". They go to great pains not to publish their results and schedules.

Obviously, the next question is whether or not a governmental entity can be open enough so the public and the medical community can feel that the guidelines they put out are believable. You can, however, craft it so that the decision trees and supporting data are open to public scrutiny. You will still have people rending garments and wailing over specific cutoffs and decisions - it will never be a cut and dry activity. However, you cannot leave it to any for profit entity. The temptation to cheat is simply too large.

Misleading Title

[LightPhoenix7]

While I understand the need to have a catchy title, it's grossly mis-representative of the problem. Doctors don't hate science - doctors hate the misapplication of science and the failure to apply common sense. Hence, pap smears for patients without a cervix.

Re:Misleading Title

[Daniel Dvorkin]

Did you RTFA? The whole point is that many physicians are doing things, such as pap smears for women without cervixes, which are contrary to both science and common sense -- and they react badly when informed that what they're doing is unscientific and nonensical. "Hate science" may be a bit strong, but there's no question that a lot of physicians don't care much for it when it interferes with their preconceived notions.

If we're gonna have a medicine flamewar...

[The Master Control P]

I figure I might as well throw in my two cents:

Last summer, I hurt one of my shoulders bad. It was somehow dislocated before it slipped back into place. I'm well aware that this does a good job fucking up the joint. For the first week, it was a dull ache that got acute when I moved my right side at all. I couldn't swing my arm backwards past straight out, to say nothing of doing any pushups. It's been about 4 months now and I can finally just about lay down on my back arms-straight-up without any nagging pain.

We can't afford health insurance so I never even considered seeing a doctor. Why risk getting raped for half a semester's tuition just so they can either say "you'll get better" or recommend more things we can't afford?

Now go ahead, tell me it's my fault for not working hard enough to have insurance or that I'd have to wait in line in England. At least there someone will eventually take a look at it.

Re:If we're gonna have a medicine flamewar...

[PCM2]

Where are you getting this "half a semester's tuition" figure? A visit to a doctor's office doesn't cost any more than a visit to a hair stylist, and it takes a lot less time. You can fill a prescription for three months' worth of painkillers at Wal-Mart for $10.

I honestly don't get it. If your car got a bad flat you'd buy a new tire. You'd tell yourself "I have no choice." But when it's your own body that breaks down, instead of paying to get it repaired, you'd rather complain about it and act like you're a hero for enduring the injury. As a result, you'll probably end up with advanced arthritis at a young age and you'll never regain full physical function. Way to go.

The system favors compliance over logic

[aswang]

1. Private insurance will not pay for a woman's well visit if they don't have a Pap smear. They don't care that the woman doesn't have a cervix. If you don't do it, you don't get paid, and it's just easier to do it no matter how nonsensical it is than it is to get on the phone with someone who is not medically trained and argue that, yes, you did do a well woman exam even though you didn't do a Pap smear.

2. There is a case to be made for anal Pap smears, because HSV also causes anorectal cancer in people who participate in anal sex. Unfortunately, because it's not standard of care, private insurance won't pay for that either. (We don't even need to talk about Medicare or Medicaid because they don't pay for preventative visits.)

Insurance company propaganda

[NewYorkCountryLawyer]

If you want my opinion, the article sounded suspiciously like insurance company propaganda. The doctor is the one person in the equation who basically has the same vested interest the patient has -- keeping the patient alive.

The cost effectiveness arguments she makes are bunk. E.g., if the old line drugs for schizophrenia are so great, why haven't they worked? And why is dehydrating someone the best way of treating high blood pressure? Give me a break.

Politicians may hate science, and certainly the health insurance companies hate science, and both like to think in terms of cost effectiveness, unless of course it's their own health that's at stake, in which case they want the best "science" available. And maybe some journalists hate science if they've absorbed enough behind the scenes insurance lobby propaganda.

But of all the groups mentioned in the article, it is the doctors who hate science least, and who are most about trying to find the right answer, the right answer meaning the one that is best for the patient's health, as opposed to the insurance company's bank account.

(And in case you're wondering, I'm not a doctor, and have never even had any relative or personal friend who is a doctor; but I do remember my first doctor, who had, under a large glass dome, a giant gold microscope, which occupied the central place of honor in his office... a clear homage to his love and reverence for Science. And in practice he cared for the lives of his patients as though they were his own. And I guess they were.).

EBM vs. the Art

[Stickerboy]

If practicing medicine consisted of a video game or a board test, then yes, doctors could suspend their own judgement in favor of strict evidence-based medicine. Unfortunately, this is the Real World, and doctors frequently have to approach EBM with a healthy dose of skepticism.

The problem with EBM is threefold: the evidence record is necessarily incomplete; many real-world patients have very little in common to patients that make it through selection criteria into randomized clinical trials (RCTs); it is very easy to skew studies in minute ways through endpoints, study design, and a thousand other ways that are difficult for busy practicing physicians to catch.

Want some examples? A recent multicenter study (in worldwide sites) of blood pressure medications funded by the maker of Lotrel found that their combination ACE inhibitor/calcium channel antagonist (CCA) had slightly better morbidity/mortality outcomes over a given period of time than patients who were placed on a combination of the ACE inhibitor and a thiazide diuretic, with similar reductions in blood pressure. The data is fantastic, and the outcomes are probably real. But when you check closely into the outcomes criteria, one of the "bad" endpoints is "hospitalization for unstable angina" (new or worsening chest pain). One of the indications that CCAs have that diuretics do not is the treatment of angina. CCAs, through the mechanisms of its action, can prevent anginal episodes or make them better. A thiazide diuretic will not treat angina directly. Out of the room of ~20 doctors this study was being presented to, apparently I was the only one who thought of this. And since many of the patients involved in the study had prior cardiac history with ostensible angina, it made perfect sense why CCAs would perform better for these patients. But this study is not being billed as that - the study is being presented as evidence of the possible superiority of using one drug over another in the general population with high blood pressure.

And then there's the Nexium/Prilosec fiasco. Nexium was developed by the makers of Prilosec when patent protection for Prilosec began running out. (You can buy generic Prilosec (omeprazole) over the counter.) Nexium (ESomeprazole [emphasis mine]) is filtered Prilosec - the biologically active enantiomer of Prilosec's racemic mixture. Nexium is on average six times more expensive, mg for mg, than generic omeprazole. The only study I know of (and that is certainly being quoted in wide circulation) comparing the effectiveness of the two was funded by the makers of Prilosec and Nexium, comparing healing rates of acid-reflux esophagitis with "typical" doses of Prilosec and Nexium. Nexium outperformed Prilosec in healing the worst grades of esophagitis - grades C and D. The "typical" doses used were 20 mg of Prilosec and 40 mg of Nexium. As this is the evidence out there, many doctors consider Nexium to be a "stronger" or "better" acid suppressor than Prilosec. I'll let the reader make the logical conclusions.

And let's talk about "typical" patients and the dearth of them in the evidence record. On an inpatient service today, I saw a "typical" patient hospitalized for a hypertensive emergency. He was a type 2 diabetic (DM)(uncontrolled) who came in with a blood pressure of 180s/120s. He has diastolic congestive heart failure (CHF) from his long-term uncontrolled hypertension (HTN). He also has chronic kidney disease probably due to a combination of his smoking, his DM, and his HTN. He also has an exacerbation of his bad chronic obstructive pulmonary disease (COPD) from his smoking. Now the evidence suggests that I place him on a beta-blocker to treat his HTN and his CHF concurrently. But beta-blockers are relatively contraindicated in acute exacerbations of COPD. The evidence suggests that I place him on an ACE inhibitor to treat his DM and HTN, but that would decrease his kidney function, and he's already at the tipping point of needing dialysis so

Re:EBM vs. the Art

[Stickerboy]

>I'm sure if you did a study of "average" gastroparetics you could say "due to evidence-based medicine, everyone should take medicine X", and this might be fine for 60% of the patients while forcing 40% into ineffective treatment. Medicine needs to address the individual needs of patients.

Exactly! To bring up a further point about patients as individuals, the Government just announced that testing PSAs for men over 75 is pointless. Which is ridiculous; their entire line of reasoning is based on the odds of the patient dying of something else before they die of prostate cancer. And now let me bring up my father, who had his PSA tested around the age of 75. Unlike most of America, he eats right, exercises nearly every day, has never smoked and has drank alcohol sparingly. He is the perfect candidate to get further PSA testing, because he is less likely than your average American to die of "something else" in the case he has an indolent prostate cancer. Which, in fact, he did - an intermediate-high grade (Gleason 7) prostate cancer that was still local and eminently treatable. But following the Government's advice today for "Best Practices", he would have stopped testing, and this malignancy would have metastasized and in all likelihood killed him.

Re:that sounds like overgeneralization

[Stickerboy]

>There's levels of generalization between "treat all men over 75 as an identical class" and "every person must be treated as a unique individual". You could, for example, segregate outcomes by a few major factors, like reported levels of exercise, weight, smoking vs. not, amount of alcohol consumption, etc.

You're absolutely right. And these intermediate levels of generalization is what leads a physician to treat patients as individuals, not as numbers. The governmental guidelines do NOT say, "Don't test men over 75 for prostate cancer, unless they're relatively or absolutely healthy." Nope, they say, "Don't test. Period. There is no evidence of benefit." It doesn't matter if the lack of evidence is because they're right, or because no one has looked into doing the appropriate studies to determine if there are some men over 75 that would substantially benefit from getting checked for prostate cancer.

There is always a grey space between clinical judgement and EBM. (Those intermediate levels of generalization that you talked about, but haven't been studied in appropriate detail.) And I will always err on the side of treating a patient as an INDIVIDUAL, rather than treating a patient as a NUMBER.

Re:EBM vs. the Art

[Stickerboy]

>>"Real world patients do not step out of a cookie-cutter, and cookie-cutter medicine (which is what EBM zealots really are promoting) does not always equal best practices."

>This is where you are wrong. Patients are rarely unique in any meaningful way, most get better on their own.

Who the hell are you? I see patients on a daily basis. Most of them have underlying illnesses (or non-illnesses) that are similar to other patients. But most of them also have their own idiosyncrasies that contribute to their direction of care and treatment. They are certainly unique to the point where I have to think about what treatments the patient will derive the most benefit from. And many of the patients I see, rather than "get better on their own", are already far down the path in the other direction, the one that leads to an early exit from this life. It is my job to head them back in the right direction (assuming the patient wants to turn their health around).

>For instance, if you come in with back pain after twisting and lifting an object, the doctor should rule out any obvious problems then send you home (maybe with a scrip for a painkiller). They shouldn't send you for an Xray because there might be something.

I'm confused. You think doctors should rule out "obvious" problems, and yet checking an X-ray or other imaging for "obvious" back problems is out of bounds, even if their story and/or symptoms might suggest a more serious problem than muscle strain? You seem to be under the impression that 100% of patients that come in with acute low back pain "after twisting and lifting an object" have a non-serious complaint. There are plenty of serious problems to consider that could stem from a twisting and lifting injury, starting with serious lumbar disk disease.

>If your pain does not resolve after a period of time, THEN you order an Xray.

Even if your clinical suspicion is high that there is an underlying problem? Even if the physical exam is troubling? You're a genius! If only ERs handled chest pain complaints like you want back pain to be handled. I could certainly prove that most people with chest pain in the ER have a non-serious complaint. We could send them all home with conservative treatment, and THEN admit them if their pain doesn't resolve! Think about the cost savings! Especially from those that die without getting expensive heart caths and bypass surgery!

>If that doesn't show anything, THEN they refer to a specialist.

Fantastic! I would think that if the imaging indicated a diagnosis that could likely benefit from a specialist treating the problem, THEN I would send them to a specialist! But what the hell do I know? Let's send all the people with no evidence of structural back disease to the specialists for... what? Re-imaging?

>And even if it does show a significant finding, it might be irrelevant (most people over 40 have abnormal backs).

What curious thinking. So someone that has an abnormal health state shouldn't receive treatment, if there are sufficiently enough people in their age group that have the same problem? Interesting. By the same token, should we stop treating heart disease in everyone over 60, because older people will invariably have some degree of heart disease? I am certainly glad you won't be directing my medical care as I age.

This is very *very* dangerous

[Secret Rabbit]

Yes, we all know that (arguably) most docs don't keep up with the literature. Or they choose a treatment and stick with that because it worked the best at one point and they like it because they trust it. Problem is, that research is ongoing and new things are found all the time. In fact, on one of my clicking adventures on-line, I found out that Lithium Carbonate was being used to treat refractory depression (as an adjunct), OCD, cluster headaches and even ALS (the one that Stephen Hawkins has) to name a few. All that in *low* doses. Yet, most docs still consider this a horrid drug refusing to realise that in low doses Lithium Carbonate does _not_ require close monitoring.

So, this sort of study could be very beneficial.

HOWEVER, it's things like this that HMO's really *really* like. They'll probably use it to force doctors into treatments that are cheaper alternatives regardless of that particular patient. Because, as with many things, certain disorders, etc, have different drugs to treat them. Different drugs for different sets of symptoms, different severity of symptoms, etc, etc, etc. So, patients will likely get cheated out of drugs that would be more effective for them simply because there HMO won't pay for the one that is best for them and the one that is best for them isn't in there price range. Especially, for the more complicated disorders.

And what happens when next week happens and this changes. How often is this list going to be updated? How often are the HMO's going to be updating from the research?

Quite frankly, while I fully believe that this thing is undertaken with the best of intentions, it is ripe for abuse. In the end, it is my opinion, that it'll likely lead to more harm than good.

Only "scientists" who get their "facts" wrong!

[hherb]

A few facts first:
1) Pap smears still make sense in women after a hysterectomy. It is then called a vaginal vault smear. It is meaningful at the very least in women who had abnormal smears prior to hysterectomy, because abnormal cells can have spread to the surrounding vaginal wall

2) Some surgeons leave a stump of the cervix behind when they perform a subtotal hysterectomy. Not common practice any more, but used to be very common in many countries and can have some advantages for the stability of the pelvic floor. Not all women who had a hysterectomy know whether they still have a cervix stump or not.

3) When the hysterectomy was performed for malignancy, eg cancer of the uterus, the vaginal vault smear can be useful to detect early recurrence

Hence. some women may not need pap smears after a total hysterectomy - but in many women this is still a meaningful and cost effective procedure - which is why even public health systems are still happy to pay for them.

The article does not seem to take this properly into account - because most scientists have only a very limited insight into medical problems. I should know - I did a science degree first before becoming a MD.

Evidence-based medicine

[gravos]

Evidence-based medicine is not the norm in the US, but you can't necessarily blame the doctors for failing to consider it: the whole system is the problem. Consider the case of Dr. Daniel Merenstein, a family-medicine physician trained in evidence-based practice.

In 1999 Merenstein examined a healthy 53-year-old man who showed no signs of prostate cancer. As he had been taught, Merenstein explained ... there is little evidence that early detection makes a difference in whether treatment could save your life. As a result, the patient did not get a PSA test. Unfortunately, several years later, the patient was found to have a very aggressive and incurable prostate cancer. He sued Merenstein for not ordering a PSA test, and a jury agreed--despite the lack of evidence that it would have made a difference. Most doctors in the plaintiff's state, the lawyers showed, would have ignored the debate and simply ordered the test. Although Merenstein was found not liable, the residency program that trained him in evidence-based practice was--to the tune of $1 million.

Re:Evidence-based medicine

[girlintraining]

The problem is when you introduce two separate institutions that were never really meant to interoperate. There is a perception by the general public that doctors should be like House, or Scrubs, or a dozen other TV shows out there where everyone is a genius, and the cure can be found in a 1 hour episode with just a few tests, a quick flip through a book, and some snarky commentary. It's the same with criminal investigations -- the so-called "CSI effect". Juries now want "DNA evidence" to prove someone was at a scene (or not), something that's both impractical and often unnecessary, and cases have been lost simply because the evidence was "too boring".

The truth is doctors aren't geniuses. They sat next to you in high school. Some of them copied your answers on the math test. They are average everyday people that have been trained (hopefully well) to do a specific job. When the justice system (and the general public's expectations) meet the medical establishment, it's not pretty. Evidence is poorly understood, and when people don't understand something intellectually they fall back on their gut feelings, their emotions. As horrible as that sounds (and sometimes is), what can we really expect from Joe Average? A carefully-weighed judgment, with full knowledge and understanding of the evidence? Please.

Here's a hard truth to swallow: All that stuff about a "jury of your peers", and being judged by people who are well versed in the law (but not necessarily the material issue at hand), doesn't work in modern society. Our method of voting and elections are horribly outdated as well, and there are dozens of systems which (at least statistically) would provide "better" results. But we as individuals want to believe we understand things well enough. We want to believe that we are righteous, and just, and overall good people. And we very well may be, but that means exactly dick in the larger equation. Just as we have specialists in medicine, technology, and elsewhere, we need a justice system, a political system, and other institutions to mirror society in it's specializations -- judges who have IT training, or medicine, etc. Politicians who make decisions about, say, telecommunications who have worked in the industry. Because society has become too complicated for us to have just judges, or just lawyers, or outdated concepts like a "jury of our peers"... Who's only qualifications were that they registered to vote in your county.

If you want change, start by choosing the right people for the job, because contrary to popular belief in this country, not just anyone can do these things.

Re:Evidence-based medicine

[PopeRatzo]

There is a perception by the general public that doctors should be like House, or Scrubs

Almost. The perception is that doctors should be like doctors were before a medical license became a ticket to becoming a millionaire. There was really a time when a successful doctor might have the nicest house on the block, but not also a nice house in St. Lucia and a nice house in Aspen and a nice apartment on the Gulf Coast. So now doctors fear that if we have universal health care in the US, they might have to go back to being part of the community in which they serve. The people who are going into medicine these days are doing so because there were no more spots left at Northwestern's B-school. Forget for a moment that our insurance-driven system has turned medical practitioners from independent actors into assembly-line employees. The 30%-plus profit margins that are built into every medical cost are going less and less to pay for the doctor's new Mercedes (or for their mistresses' breast implants) and more and more to the pockets of companies that have nothing to do with medicine. I actually lived in a time when almost all hospitals were non-profit, but that was back in a rosier time in our history when we had a booming economy and a 90% top income tax bracket (go figure).

We have learned that "free market" medicine does not guarantee a healthier populace, nor does it even guarantee the best health care system.

Of course doctors hate science. They're afraid that it might show that the product they provide is overpriced and ineffective. Then we'll end up with socialized medicine, which as we are constantly told is only one step away from gulags and a Supreme Soviet.

Re:Evidence-based medicine

[EvolutionsPeak]

Have fun trying to get well educated doctors if you aren't going to pay them. I sure as hell am not going to go through 10 years of schooling and assloads of debt just to make a wage I could have made with 4 years of school.

Re:Evidence-based medicine

[tburkhol]

I sure as hell am not going to go through 10 years of schooling and assloads of debt just to make a wage I could have made with 4 years of school.

M.D.s get 4 years undergrad, 4 years med school, and a few years residency. They follow the standard of practice as they learned it with starting salaries around $100k/year.

Ph.D.s get 4 years undergrad, 5-6 years grad school, and a few years postdoc. They advance the state of art, train the physicians, and the engineers, and everyone else, with starting salaries around $60k.

Money is not the only motivator, and if you make it the major motivator, they you're not going to attract talented, well-educated people. You're going to attract people who are motivated by money.

Re:Evidence-based medicine

[Falconhell]

Ahhh, never let the facts interfere with a good rant eh/

In most countries that have socialized medical,
it is only elective (Non essential) surgery that has waiting lists. Life saving surgery is done straight away. So you face lift might have to wait but your bad heart will get immediate attention.

I live in Australia where we have public healthcare, and I have always found it pretty good.

No fund (HMO) accountant decides your treatment (Even in the private care insurance system) here either. That you allow accountants to decide what treatment you get and then try to put down universal healthcare is stunning.

Re:Evidence-based Professional IQs

[binarylarry]

Well then, if iqcomparisonsite.com says so, it must be true!

Oh look! I just won a free ipod!

- Dr. Nick

Re:

[rev_sanchez]

Following a recognized best practices protocol could provide some legal defense in cases like this while providing better care at a lower cost. In practice it certainly won't be that easy. It does tend to turn the practice of medicine into a game of 21 questions to start identifying the problem and a checklist to treat it but a fill-in-the-blank style of treatment could make their paperwork go faster too.

Re:

[PopeRatzo]

t does tend to turn the practice of medicine into a game of 21 questions

Maybe that's what it's supposed to be.

Re:Evidence-based medicine

[Genda]

This simply demonstrates that the system is being rigged by a culture of "Get Rich" thinking. A significant number of people practicing medicine today shouldn't be allowed to practice playing a Kazoo, and they're in it, because they thought they could make a lot of money (plastic surgeons who shouldn't be allowed to butcher meat seem to spring to mind first.) Insurance companies who keep jacking malpractice insurance into further and further into space, happy to support hospitals in charging 10,000% markups on supplies, because it allows them to justify taking larger and larger cuts without looking like they're the source of the problem. Lawyers looking to sue at the first instance of a patient passing a particularly unpleasant flatus. Drug companies whoring out doctors to peddle their products, making silly analogs that are less effective than 20 year OCR alternatives, but pushing these pseudo-new-drugs at top dollar because the can bring in massive profits with little or no research. Finally patients, suing anyone and everyone for the most ridiculous and insane excuses. Did I say finally? Forgive me. A government made up of lawyers who've meticulously built a system that empowers every one of these participants in pursuing endless litigation, all in desperate hope of winning their personal legal lottery ticket.

Returning medicine to a social service designed to promote health and treating illness would solve the whole problem. Unfortunately, as long as you have this financial circle-jerk, with each participant's hand in his neighbor's pocket greedily digging for what only God knows, the chances of any sanity coming to this venue are slim and none. In short, anybody with more that two neurons to rub together would have to agree, it's a total botch, and we need to overhaul it if there's any hope of it getting fixed. Sadly, the folks most engaged are the ones who have the most to lose, and the ones who will fight hardest to keep taking as big a slice as the limits of avarice and capital punishment will allow.

Re:Evidence-based medicine

[Anonymous Coward]

Data is not the plural of anecdote.

Re:Evidence-based medicine

[MR.Mic]

No, anecdote implies that the information is second-hand, can not be verified, and is therefore unreliable.
Actual scientific data is first-hand and verifiable.

Re:Evidence-based medicine

[evanbd]

There's another problem with anecdotal evidence -- selection bias. Some anecdotes are amenable to rigorous investigation and verification; when that happens they get called case studies instead. They're very useful, but they're not the same as broad-scale survey data, even when available in large numbers. The interesting cases turn into anecdotes, the boring ones get ignored, resulting in various forms of selection bias.

Anecdotes can tell us that something is worthy of further study. In order to conclude (for example) that PSA tests are meaningful, we need a statistically sound sample including people who both did and didn't get PSA tests. Even when the anecdotes are well researched and verified, their plural is not data.

Re:Evidence-based medicine

[Anonymous Coward]

A second hand is involved? I'm NEVER having a colonoscopy. D:

Re:Evidence-based medicine

[justthisdude]

I used an anecdote once, and it was like TOTALLY reliable. Besides, I read a study in O magazine that said that 4 out of 5 statistics are completely made up.

Re:Evidence-based medicine

[Random BedHead Ed]

I used an anecdote once, and it was like TOTALLY reliable. Besides, I read a study in O magazine that said that 4 out of 5 statistics are completely made up.

I know this guy who says it's really more like 4.5 out of 5.

Re:Evidence-based medicine

[Zironic]

The relevant question is not how common the test is.

The relevant question is, would it have made any difference?

Re:Evidence-based medicine

[pallmall1]

The relevant question is not how common the test is.

You're right about that not being the relevant question. The relevant question is:

Why is this included in an ECONOMIC STIMULUS PLAN?

Because it stimulates the economy

[Nicolas MONNET]

As Paul Krugman said it, with the economy in this kind of state, you have to pay people to dig holes and fill them back up. If something good can be done instead of something useless, that's just a bonuns.

Re:Evidence-based medicine

[neoshmengi]

I'm 53 and my physician makes a regular practice of PSA tests for men my age, actually I started having them @ 50. Also just had my first colonoscopy recently and good thing as I had one tumor removed that was pre-cancer.

This is rule of thumb, and Dr. Merenstein should have known this.

Actually the previous poster is right. Population based studies suggest that more harm than good is done by screening for prostate cancer.

The evidence goes like this. Once you have an elevated PSA, you see the urologist who orders a biopsy. Biopsies and treatments for prostate cancer carry risks like bleeding and infection, urinary incontinence and impotence. Now most prostate cancers will not kill you or cause problems in your lifetime. So investigations and treatments for prostate cancer cause more harm to people than the cancer does. This makes sense in a population, but not to the guy who got a bad cancer.

The current guidelines do not suggest PSA's in all men over fifty, but rather that you discuss the risks and benefits of screening, plus potential harm of further workup of a positive screen vs. the harm of developing prostate cancer. In practice, there is no patient who can actually understand enough of this to truly make an informed decision. Many docs haven't heard of the 'new' evidence and continue screening. The ones who do know of that evidence often ignore it because it's hard to explain, and patients will love you for finding an early cancer, even if it would never have affected them.

As far as your colon cancer screening comment, what you describe is standard of care.

The other thing to consider is that medicine in the US is HUGELY biased by the litiginousness of US culture. US emergency medicine guidelines, for example, are extremely aggressive and notorious for over investigating. The priority is protecting practitioners from litigation rather than appropriately treating the patient. A lot of those investigations are not recommended in socialized health care systems because they are not cost effective, nor do the benefits outweigh the disadvantages.

Re:Evidence-based medicine

[DrLang21]

US emergency medicine guidelines, for example, are extremely aggressive and notorious for over investigating.

Good God I know this part first hand. I went to the ER because I had chest pain in my left side. I'm young, so I thought heart problems were highly unlikely but better safe than sorry. The doctor that saw me surmised that it was probably an irritated GI tract, which I know that I have problems with, and was nothing serious. Then he proceeded to order blood tests, CT scans, and others. I said screw that and refused treatment. A nap did just fine to make the problem pass. Again, some evidence suggests that CT scans may do more harm than good, and really should only be used when necessary. Diagnosing constipation is hardly a proper use for a CT scan and racking me up a couple thousand dollars in medical expenses.

Re:Evidence-based medicine

[twostix]

To throw in a real world data point to back your claim, my healthy, active and vibrant 82 year old grandfather went in to have an operation to deal with prostate cancer, his doctor suggested that as he was in such good shape if he got rid of the cancer he could live on for quite a while longer.

He died suddenly in the hospital from internal bleeding caused by the surgery a few hours later. Now the cancer might have gotten him eventually, but how long, five years? ten? He was 82 and healthy and happy so it was kinda pointless operating really.

He thought so too, but let himself be talked into it by his doctor.

Worst thing was he was completely lucid, happy and rational minutes before he died, it was very sudden and unexpected.

Re:Evidence-based medicine

[NIckGorton]

US emergency medicine guidelines, for example, are extremely aggressive and notorious for over investigating. The priority is protecting practitioners from litigation rather than appropriately treating the patient.

Actually one of the big reasons that EM diagnostic evaluation is more aggressive than usual is that (shock) patients actually do have a hint of what is important. That is, if you take a random person who goes to his family doc with chest pain versus one who goes to the ER the former is less likely to have significant coronary artery disease. So its not surprising that if you compare ER with primary care, it is good medicine to be more aggressive with diagnostic evaluations in the ER.

That said, hell yeah as an ER doctor I sometimes practice defensive medicine. If you place me in an environment where people can effectively sue me for what I might make full time in 20 years for a bad outcome that happens despite me practicing medicine that meets the standard of care in my practice environment I sure as hell am going to practice defensive medicine. The fact that I don't always do aggressive diagnostics in every patient is either me being a Pollyanna or perhaps taking my patient's best interests at heart. I'm willing to put my neck on the line somewhat to avoid a CT in a toddler who just has overprotective parents, but your fat, diabetic, smoking, sedentary, litigious ass is just not cute enough to get the my sympathy.

Re:Evidence-based medicine

[Fluffeh]

I'm 53 and my physician makes a regular practice of PSA tests for men my age, actually I started having them @ 50. Also just had my first colonoscopy recently and good thing as I had one tumor removed that was pre-cancer.

This is rule of thumb, and Dr. Merenstein should have known this.

Could we please refrain from talking about a colonoscopy and using the phrase "rule of thumb" in one post?

Re:Evidence-based medicine

[PopeRatzo]

Unfortunately this is severely mitigated by two groups - lawyers and patients.

Yes, medicine would be a great career if it weren't for those inconvenient patients.

Re:Evidence-based medicine

[NewYorkCountryLawyer]

no doctor hates science, and the medical profession as a whole are champions of scientific thinking when most other professions have yet to be introduced to the concept.

I agree.

Unfortunately this is severely mitigated by two groups - lawyers and patients. The original article could equally be titled 'why lawyers hate science' - as the parent says, many judgements against doctors are based on whether something could have been done, not whether there was evidence to support doing it, or even whether it would have been effective.

That is sheer and utter nonsense.

Patients come to doctors with the expectation that something will be done

What's wrong with that?

and a significant part of medicine is allaying the fears and anxieties of the patient.

1. That's not the "medicine" part, that's hand holding. And any way
2. What's wrong with that?

The cover-your-ass imperative imposed by lawyers

The only "imperative" imposed by the courts is that "reasonable care" be applied? Why is that so terrible? Why is that so onerous? Most medical care is far, far above that relatively low standard.

and the demands of anxious patients significantly skew treatment away from the scientific ideal

Nonsense.

- the desire to make money (while also significant) is a distant third, and largely reflects that monetary incentives in private medicine do not match well with the interests of the patient (i.e. a systemic funding problem).

Oh yeah and the insurance companies' financial interests do match up?

But the title of the original article - implying that doctors hate science - is utter crap.

On that we can agree.

Re:Evidence-based medicine

[neoshmengi]

Unfortunately this is severely mitigated by two groups - lawyers and patients.

The original article could equally be titled 'why lawyers hate science' - as the parent says, many judgements against doctors are based on whether something could have been done, not whether there was evidence to support doing it, or even whether it would have been effective.

That is sheer and utter nonsense.

I wish it were nonsense. There was a US case about a patient who had an acute spinal cord injury. There is a controversy about whether or not to give steroids in these cases to reduce swelling and decrease subsequent injury. So far the consensus is that it doesn't help. The ER attending physician therefore did not give steroids. The patient had a bad outcome. The ER attending was found guilty (not sure what the correct term is) because the prosecution found an expert witness who said that it might have helped.

The only "imperative" imposed by the courts is that "reasonable care" be applied? Why is that so terrible? Why is that so onerous? Most medical care is far, far above that relatively low standard.

The difficulty is in defining reasonable. It seems that some lawyers are very good at skewing this definition.

Most physicians practice 'defensive medicine'. That means they do things that are medically unnecessary, solely to protect themselves from frivolous lawsuits. Good medicine alone unfortunately won't protect you from malicious (or vulnerable and wounded) people, looking for someone to blame.

I can tell you a number of cases where the physician was found guilty and they did nothing wrong. The jury just didn't like how things turned out for the patient.

(Big fan of yours by the way!)

Re:But CER is government control

[ColdWetDog]

Yeah, it's Newsweak, and this is a pretty lame piece. For one, the title "Doctors Hate Science". Just a wee bit of overreach, worthy of kdawson (maybe that's why he put it up).

Next up:

If bureaucrats were in charge, physicians might have to prescribe the newest hypertension drugs as a first-line therapy, do MRIs to diagnose back pain and give regular Pap tests to women who have had total hysterectomies.

Which conflates the argument that doctors sometimes do those (and other) stupid things. They don't have to....

And another gem:

It's hard not to scream when you see how many physicians, pharmaceutical companies, medical-device makers and, lately, hysterical conservatives seem to hate science, or at best ignore it. These days the science that inspires fear and loathing is "comparative-effectiveness research"

What the fuck is wrong with this woman? Did somebody do a prostate exam on her? Yep, there is a problem - doctors don't necessarily do what sometimes iffy research describes as best practices. And there is the big issue of why medical practice varies so much from region to region. And doctors very definitely tend to do things that pay them money (i.e., procedures) when perhaps they are better off not doing so.

But this 'article' is just an idiotic rant. There are fairly large and well funded groups that find it in their best interest not to go along with this idea, but to paint everybody with the same brush and to dismiss detractors of CER is just immature. Unfortunately, for the vast majority of patients, we really don't know what is the best combination of treatment or not treatment. Most of the studies have been done for fairly short periods of time and on rather homogeneous populations. It's hard to know how those studies apply to the real world patient in your office.

Let's take the little issue of pap smears after hysterectomies. If you had a hysterectomy for actual cervical cancer, then you ARE supposed to keep getting pap smears (at some unknown frequency). That's because cancerous tissue doesn't necessarily stop growing the moment it wanders off it's initial tissue base. That's why it's a cancer.

Way to go Newsweek. Take an important, complicated issue and create a brain dead sound bite.

Roll up your sleeve and bend over.

Re:Random quote

[rthille]

The quote I like best is: "What do you call 'Alternative Medicine' that works?" "Medicine"

Re:

[bersl2]

Why can't we just have one general "cancer test" developed for all kinds of cancer that exist, be it cervical, breast, lung, kidney, colon, etc? Our technology is as advanced as it can get for this day and age.

CANCERS DO NOT WORK THAT WAY!

They have the same general properties (a condition of abnormally frequent cellular reproduction), but the mechanism of how each one works is different. If we consider the biological definitions of the terms, they are analogues but not homologues.