Respectful Insolence

If there’s’ one theme, one cause, that this blog has emphasized throughout the four years of its existence and the three years of its having resided on ScienceBlogs, it’s been to champion science- and evidence-based medicine over pseudoscience and quackery. Whether it’s refuting the lies of antivaccine zealots, having a little fun with some of the more outrageously bizarre forms of pseudoscience, railing against cancer quackery, lamenting how easily pseudoscientific quackery has infiltrated medical academia, complaining about drug companies rigging clinical studies, or trying to educate my readers about the complexities of cancer screening, support for science- and evidence-based medicine has been one of the two or three constants on Respectful Insolence since its very beginning. Indeed, I personally have even lamented at how little of the scientific method is taught in medical school, far too often emphasizing facts over critical thinking, leaving most physicians woefully unversed in the scientific method. This shortcoming has led some doctors to become creationists and some to embrace other pseudoscience. If anyone thinks that more science in medicine would be a good thing, it’s me.

That’s why I feel entirely justified in calling out medical correspondent Sharon Begley as being full of shit for her exaggerated attack on doctors entitled Why Doctors Hate Science.

Begley begins:

Thank God doctors in the United States are free to treat patients as they deem best, free from interference by faceless bureaucrats. 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. Oh, wait–they do. All these medical practices are common, despite rigorous studies showing how useless or wrongheaded they are. Definitive studies over many years have shown that old-line diuretics are safer and equally effective for high blood pressure compared with newer drugs, for instance, and that MRIs for back pain lead to unnecessary surgery. And those Pap tests? Total hysterectomy removes the uterus and cervix. A Pap test screens for cervical cancer. No cervix, no cancer. Yet a 2004 study found that some 10 million women lacking a cervix were still getting Pap tests.

Well, well, well, well. Begley appears to be trying to match Orac for sarcasm and insolence. Note the contempt dripping from her every sentence, contempt for doctors, contempt for medicine. The main difference is that Orac (usually) gets his facts right. For example, she takes what she thinks to be a slam dunk example of the pap smears after hysterectomy and uses it to indict doctors as “hating science.” However, let’s see what the Mayo Clinic website, for example, has to say about the matter:

If you had your uterus and cervix removed (total hysterectomy) for a noncancerous condition, you may be able to stop having Pap smears. However, if your hysterectomy was for a cancerous condition or you had your uterus removed but your cervix remains intact (partial hysterectomy), you still need regular Pap smears. In either case, regular pelvic exams and mammograms are recommended.

Indeed, I found the paper to which I believe Begley is referring, which came out of my alma mater ( the University of Michigan) in 2003. It refers to only the case of pap smears after hysterectomy for benign disease. Begley may indeed have a point that too many pap smears are still done after hysterectomy, by simplifying and mocking she completely undermined her point–not to mention showed that she doesn’t understand the issues involved. Either that, or she does understand them but decided to score cheap points against physicians instead of adding three words after “hysterectomy”: “for benign disease.” Not surprisingly, several doctors took her to task for her distortions. At the very least, Begley should have acknowledged that her blanket statement is more than a bit over-the-top and that the issue, at least in the case of hysterectomy after malignant disease, is not as cut and dried as she thinks. Even if it were, understanding why doctors have been too slow to give up this practice is not what she is about. Bashing doctors is.

Of course, I am not arguing that any of the shortcomings of medical practice mentioned by Begley are a good thing or that they shouldn’t be changed and, presumably, improved. I’m not even arguing that she doesn’t have a point. What I am arguing is that she chose to make that point in the most simplistic and inflammatory way possible. Regular readers of this blog know that the lack of science behind all too much medical practice is something I work to change every day and that I complain about it right here (and elsewhere) on average at least once a week, if not more often. Rather, what bothers me about Begley’s article is the way she takes some observations about how medicine is practiced and then makes the leap to conclude that doctors hate science:

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” (CER), which is receiving $1 billion under the stimulus bill President Obama signed. CER means studies to determine which treatments, including drugs, are more medically and cost-effective for a given ailment than others.

And it’s hard for me not to scream when I see hysterical journalists leaping to the conclusion that doctors “hate science” and then likening them to “hysterical conservatives” on the basis of what, let’s face it, is her own personal political views, the existence of regional disparities in health care, many of which are systemic in nature and whose causes are not nearly as well known as Begley would lead you to believe; and shortcomings by doctors in applying science to medical care. Again, I call opportunistic ideological bullshit on this article. Unfortunately, instead of trying to understand why there might be regional disparities or why doctors might have difficulty adhering to science- and evidence-based treatment guidelines, Begley decides to go for cheap political points and use these disparities as an easy excuse to attack physicians and conservatives (which, although Begley may have trouble believing this, are not necessarily one in the same).

In fact, disparities in the use of various services and medical procedures are a highly studied area of medicine. There are usually many, not few, reasons for such disparities. Begley correctly identifies one possible contributor as medical culture, but that is only one of many potential reasons, and it is likely that a combination of multiple factors are at play. Perhaps one of the more prominent reasons is that the evidence supporting different interventions over others is not as clearcut as a journalist would like it for many conditions. Where ambiguity exists, clinical judgment rules, and different regions may indeed develop different norms based on regional differences. It’s not ideal, but it’s not necessarily due to physicians “hating science,” as Begley so histrionically puts it.

Moreover, patient desires have a profound effect on how doctors practice. I’ll mention one example of a surgical procedure that was adopted long before they were validated by science because of a combination of patient demand and surgical–shall we say?–entrepreneurship. I’m referring to laparoscopic cholecystectomy. Indeed, I started my residency in 1988 and went into the laboratory to work on my PhD in 1990. Pre-lab days, I learned how to do old-fashioned, “open” cholecystectomies, and I did a fair number of them, even though I was only a second year resident. Then I went into the lab for over three years. When I came out, no one was doing “open” cholecystectomies anymore. Laparoscopic cholecystectomy had taken over in a mere three years, at least in Cleveland. What had happened in three short years in Cleveland?

Patients demanded laparoscopic cholecystectomy, that’s what, and surgeons with an entrepreneurial bent gave it to them. One can argue whether surgeons stoked the demand or simply responded to it, but there’s no doubt that nonscientific factors came into play that did involve a significant, if not major component, driven by patient demand.

What happened is that the procedure had started in a few centers, and it spread like wildfire through a combination of patient word-of-mouth, some of which was stoked by advertising by surgeons looking to distinguish themselves from the pack, but that didn’t explain the speed with which the new procedure supplanted the old. Suddenly, older surgeons were finding themselves forced to learn the new procedure rapidly or risk losing all their gallbladder business, as patients wouldn’t go to surgeons who did the “old” procedure anymore, and referring physicians wouldn’t refer to them. Yet, had science and clinical trials validated laparoscopic cholecystectomy as the equal of the “gold standard” procedure? Not at all! In fact, in the 1990s, it was noted that injuries to the common bile duct were considerably more common after the laparoscopic procedures, requiring referral to expert biliary surgeons for repair. The rate was still very low, but it was several times higher than the rate after the open procedure had been. This was attributed to the “learning curve,” but I’m not sure that accounts for all of the difference. After all, it took at least a decade before the disparity in biliary injury rates shrank to the point where it is only somewhat higher after laparoscopic surgery. This was due to more and more surgeons doing more and more laparoscopic procedures more than anything else.

Another example that comes to mind is sentinel lymph node biopsy (SLN) for breast cancer, although this was not driven quite as much by patient demand as laparoscopic cholecystectomy. SLN biopsy involves injecting dye into the breast and following that dye to the first lymph node under the arm to which it drains. That lymph node is then removed and examined. If there is no tumor there, with a high concordance, there is no tumor in the rest of the lymph nodes. From the late 1990s into the early 2000s, SLN biopsy rapidly supplanted the older procedure, the axillary dissection, which involved removing all the lymph nodes under the arm, even though it was unproven.

I say “unproven,” because there was a small rate of false negatives, in which a “negative” SLN missed a lymph node or lymph nodes with cancer. Theoretically, that meant that SLN could lead to some patients being undertreated because they are thought to be node negative when they are in fact node positive. Where I worked at the time, we did the right thing, viewing the procedure as still unproven, and only did it under the auspices of a clinical trial, namely the NSABP-32 trial until that trial’s accrual was complete. During that time, many women asked for SLN and ended up going elsewhere when informed that we would only do it as part of a clinical trial that could lead to them being randomized to undergo axillary dissection. Fortunately, short term results reveal the results of SLN to be equivalent to those of axillary dissection, but the procedure is too new for us to have long term data equivalent to what we have for axillary dissection. No matter. SLN has become the standard of care. You can look at it as either accepting that a small percentage of women who undergo SLN biopsy will be undertreated as being worth the decrease in morbidity, such as lymphedema, from removing only one to five lymph nodes under the arm instead of nearly all of them, or you can look at it as most women having decided that they would prefer not to risk nerve damage or lymphedema from an axillary dissection. Either way, the result is the same.

What Begley doesn’t seem to understand is that, although medicine should be primarily science-based, it is never going to be pure science. Too many factors other than science impact how medicine is practiced. These include the doctor-patient relationship, availability of resources, third party payors, patient preferences, the influence of pharmaceutical company advertising and P.R., the individual circumstances of each patient, and, yes, to some extent physician culture, the latter of which was pretty much the only factor to which Begley attributed all manner of evil to. Add to that the frequently conflicting and unclear evidence on so many clinical questions, and it’s no wonder that there are regional variations. And, yes, I don’t deny that there is a certain resistance among many doctors to being told what to do that sometimes leads to resistance to anything they perceive as mandating how they must take care of patients, as well as a desire to “fit in” among one’s colleagues. Where Begley errs is in emphasizing these two traits over everything else and ignoring systemic factors. In essence, she takes the easy, simplistic explanation over the more accurate, nuanced reasons.

A lot like the conservatives resisting science that Begley castigates.

Also, it’s not that doctors “hate science.” There may be a small minority who do, in fact, “hate science” because it restricts their actions (the physicians who belong to the Association of American Physicians and Surgeons immediately come to mind), but in fact most physicians actually believe that they are practicing based on science. They really do. One problem is, as both Steve Novella and Val Jones have pointed out, is a lack of resources to help them keep up with the latest scientific literature and have access to the latest science-based recommendations at the point of patient contact. Another problem, as I have pointed out before, is that most physicians are not trained in the scientific method, at least not very well. They truly do not know how to separate the wheat from the chaff, and are easily swayed by anecdotal evidence, be it their own “personal clinical observations” (shades of Dr. Jay!) or those of their colleagues, not realizing how easily anecdotes can mislead and how easily a series of anecdotes in a practice or region can lead to groupthink. Also, as Steve points out, the more certain the scientific literature is with respect to the correct treatment for a condition, the less regional variation there is in the use of that treatment. Ambiguity in evidence leads different regions to develop regional standards.

Unfortunately, not only does Begley spew oversimplified drivel as if it’s the Gospel Truth; she sees dark conspiracies against her favored solution to the problem, comparative clinical effectiveness research (CCER), painting those who are skeptical of it as either driven by money, ideology, or just downright hubris. I’m disappointed in her because I say this as someone who in general likes the concept behind CCER, namely testing different treatments for a condition head-to-head against each other and letting the chips fall where they may. What’s not to like about that, if you’re a booster of science-based medicine like me? Even so, apparently Begley is going to have to add me to her list of a money-grubbing, unscientific, clueless, conservative wingnuts, because I actually do share some of the concerns she heaps scorn upon in her article, namely that the fruits of such research could become mandates. Val Jones explains why:

Although comparative clinical effectiveness research is distinct from comparative cost effectiveness research – it is likely that payers will use CCER to build their formularies. This means that even though the government (at this point in time) is not mandating coverage decisions based on CCER, health insurers are going to be using the information liberally to justify coverage preferences and even potential denials of coverage.

That is precisely why many physicians are concerned about government-mandated CCER. It’s disingenuous in the extreme of Begley–and Dr. Elliott Fischer, whom she quoted–to deny so vociferously that CCER has anything to do with cost control and to paint those who oppose it as a bunch of right wing ideologues. True, some of them are; but many of them are not. It is also true that there is language in a Congressional report about CCER that raises a bit of concern even to me:

By knowing what works best and presenting this information more broadly to patients and healthcare professionals, those items, procedures, and interventions that are most effective to prevent, control, and treat health conditions will be utilized, while those that are found to be less effective and in some cases, more expensive, will no longer be prescribed. Substantially increasing the Federal investment in comparative effectiveness research has the potential to yield significant payoffs in reducing health care expenditures and improving quality.

Maybe it’s not being such a “scaremonger” (as Begley so quaintly put it in the subtitle of her article) to wonder how CCER will be used, after all, as Val Jones did:

There’s also the question of stifling innovation. Blockbuster drugs are rarely discovered in a vacuum. They are the result of incremental steps in understanding the biology of disease, with an ever improving ability to target the offending pathophysiologic process. The first few therapies may offer marginally improved outcomes, but can lead to discoveries that substantially improve their efficacy. If an early drug is found to be only marginally better than the standard of care, an unfavorable comparative effectiveness rating could kill the drug’s sale. Without sales to recoup the R&D losses and reinvestment in the next generation of the drug, development may cease for financial reasons, and the breakthrough drug that could cure patients would never exist.

A theoretical concern, I agree, but it’s not an unreasonable concern at all.

That being said, because I support science- and evidence-based medicine, I still support CCER. My support for only the most rigorous science and clinical research does not, however, keep me from some mild concern about whether the results of CCER will evolve from useful research results that help to guide treatment choices in a science- and evidence-based manner into a government straightjacket on medical practice. Like Steve and Val, I’d love to see the results of CCER serve as a means of helping physicians to become more science-based, not of telling them what to do and reducing treatment algorithm’s to “cookbook medicine,” although for some conditions for which the evidence is particularly clear I also agree with Steve that strong guidelines based on the scientific literature and CCER are not a bad thing. The problem is: How to blend the two approaches, top-down and bottom-up, optimally?

Another issue I’d love to see addressed but likely never will comes in the wake of Senator Harkin’s little woo-fest last week in the Senate. Personally, I’d love to see CCER applied to “alternative” medicine versus conventional medicine in a rigorous way. Indeed, if CCER is implemented, it would be one way of driving home once again how ineffective the vast majority of “alternative” medicine is and, if CCER is ultimately used to decide which treatments to reimburse, might blunt the drive “integrate” woo with scientific medicine. A guy can dream, can’t he? Unfortunately, what’s more likely is comparing woo to woo, such as head-to-head trials of homeopathy versus reiki, for instance.

In the end, though, for all the worship of CCER as some sort of panacea for the ills of regional variation in treatment practices, the continued use of treatments that are inferior, or wasteful treatments, I don’t see CCER as the be-all and end-all of scientific medicine or even its next stage. Indeed, Begley’s faith in CCER and her castigation of physicians who remain skeptical of it show that she’s utterly clueless about ever having actually tried to use guidelines such as the ones that are likely to derive from the results of CCER. After all, in oncology, we’re far ahead of the curve in developing and using science-based treatment algorithms. Indeed, just peruse the algorithms in the NCCN treatment guidelines for breast cancer. It’s 121 pages, and at our cancer center we try hard to practice within its guidelines. Even so, at our weekly breast cancer tumor board, almost every session we encounter a case that does not fit well into the treatment pathways therein.

There’s a reason for that. It’s because good medicine should be based first and foremost on science, but science alone can never completely dictate how medicine should be practiced in many cases. There are too many other factors apart from science at play. If Sharon Begley’s article is any indication, she probably thinks that my saying so must mean that I must “hate science,” just like those doctors she castigates as lazy, money-grubbing, clubby, close-minded individuals who don’t need no steekin’ science telling them what to do. Unfortunately, her simple-minded and misleading conflation of criticism of CCER with wingnuts, pharma shills, ideologues, greed, insular groupthink, and just plain hubris throws a lot more heat than light on the discussion.

Maybe that was her purpose all along. On second thought, strike the word “maybe.”

Comments

  1. #1 Samurai Scientist
    March 4, 2009

    The funny thing is, not long ago Sharon Begley blasted the scientific research establishment for being a bunch of ivory tower wankers. She said we bench scientists had “never met a signaling pathway we didn’t like,” but had done nothing to slow the rate of cancer mortalities. In that article, she criticized the scientists and idolized the physicians. Now she says it’s the other way around.

    I think she just likes to stir things up. Glad you called her out on it.

  2. #2 Jason
    March 4, 2009

    I find myself agreeing with both you and Sharon Begley. While her ~850 word article for a popular audience lacked the subtlety and nuance of your ~3130 word reply, I agree with you both that CCER is a valid and useful scientific tool. And I think we’d all agree that we need to actively work to make sure it isn’t misused (because it will be to some extent, inevitably, and we need to react strongly when lines are crossed).

  3. #3 BigHeathenMike
    March 4, 2009

    Excellent take-apart of Begley. The truths of being science-based while at the same time not being true science need to be effectively passed along to as many who will listen as possible.

    Well said.

  4. #4 BigHeathenMike
    March 4, 2009

    Excellent take-apart of Begley. The truths of being science-based while at the same time not being true science need to be effectively passed along to as many who will listen as possible.

    Well said.

  5. #5 Tracy W
    March 4, 2009

    Indeed, I personally have even lamented at how little of the scientific method is taught in medical school, far too often emphasizing facts over critical thinking, leaving most physicians woefully unversed in the scientific method.

    Sorry Orac, but here, as far as I can tell, you’ve made a false dichotomy – knowing facts is an essential part of being able to think critically. For example, knowing that you need to use a control group in an experiment is important. But you need to know a lot about your discipline to know how to create your control group – if you are in a scientific discipline where it’s not posisble to have two groups that are exactly like you need to know which factors can vary between groups.
    Facts are also essential for being able to devise research hypotheses.
    See http://www.aft.org/pubs-reports/american_educator/issues/summer07/Crit_Thinking.pdf

    Of course that doesn’t mean that medical schools are doing a great job of teaching the scientific method, but it does imply that if we want medical schools to do a great job of teaching the scientific method this is likely to mean medical schools will be teaching more facts, not less.

  6. #6 Dangerous Bacon
    March 4, 2009

    Regarding the issue of Pap _tests_ (hardly anyone does smears anymore; liquid-based systems have virtually taken over) after hysterectomy, here are the U.S. Preventive Services Task Force recommendations on Pap tests in older women:

    “Discontinuation of cytological screening after total hysterectomy for benign disease (e.g., no evidence of cervical neoplasia or cancer) is appropriate given the low yield of screening and the potential harms from false-positive results in this population. Clinicians should confirm that a total hysterectomy was performed (through surgical records or inspecting for absence of a cervix); screening may be appropriate when the indications for hysterectomy are uncertain. ACS and ACOG recommend continuing cytologic screening after hysterectomy for women with a history of invasive cervical cancer or DES exposure due to increased risk for vaginal neoplasms, but data on the yield of such screening are sparse.”

    http://www.ahrq.gov/clinic/3rduspstf/cervcan/cervcanrr.htm

    We routinely see Pap tests at my facility from women post-hysterectomy who are considered high-risk due to prior malignancies or high-grade dysplasias.

  7. #7 perceval
    March 4, 2009

    Tracy W, facts can and do change. In order to make our students “future-proof”, we need to emphasise the skills of finding facts, assessing them critically and putting them in context. I agree that students need a conceptual “skeleton” of facts and interrelationships to get them started, but that should be enough to make sense of findings.

  8. #8 Calli Arcale
    March 4, 2009

    That’s a good point that I’d never considered (probably because I’m a software engineer, not an oncologist) — if the total hysterectomy was for cervical cancer, pap tests may be even *more* important because of the risk of tumors popping up in adjacent tissue.

  9. #9 Tracy W
    March 4, 2009

    Perceval, why do you believe that only a “conceptual” skeleton of facts is enough to make sense of findings? For example, take the case of the reclassification of Pluto as a non-planet. How do you make sense of this change in facts if you don’t know what a planet is, or what Pluto is?

    And how do you believe that students can assess facts critically and put them into context with only a skeleton of facts? One thing that science teaches us is that common sense is very often wrong, so we can’t rely on our common sense to assess facts critically. (For support for this statement, go and check out Newtonian physics sometime).

    I agree that we should teach students how to find facts, as new facts change. But you cite no empirical evidence to support any of your assertions above, including that the skills you mention should be emphasised above actually teaching facts. Actual scientific evidence is as valuable in education policy as in medicine.

  10. #10 Pieter B
    March 4, 2009

    Personally, I’d love to see CCER applied to “alternative” medicine versus conventional medicine in a rigorous way. Indeed, if CCER is implemented, it would be one way of driving home once again how ineffective the vast majority of “alternative” medicine is and, if CCER is ultimately used to decide which treatments to reimburse, might blunt the drive “integrate” woo with scientific medicine.

    From your lips to Harkin’s ear. Or keyboard to eyes. Or something.

  11. #11 wfjag
    March 4, 2009

    “Thank God doctors in the United States are free to treat patients as they deem best, free from interference by faceless bureaucrats. If bureaucrats were in charge, . . .”

    I take it that Ms. Begley has never looked at the outcomes from Louisiana’s Charity Hospital System (a medical system run by bureaucrats who controlled costs)? Although free medical care was doubtless better than no medical care, 80 years of data leads to a much less rosey belief in what will occur with greater government direction over services that physicians are allowed to provide patients.

  12. #12 Wyrd
    March 4, 2009

    To me, it seems like Begley’s just being lazy.


    Furry cows moo and decompress.

  13. #13 Sastra
    March 4, 2009

    Unfortunately, what’s more likely is comparing woo to woo, such as head-to-head trials of homeopathy versus reiki, for instance.

    If we’re lucky, that could very well signal the end for so-called alternative medicine. As it stands now, the woo supporters all support each other: as long as the other form of therapy stands in opposition to the same enemy (Western allopathic medicine), then it’s an ally. Even if the underlying explanations for the problem are completely at odds, the attitude seems to be ‘Take what you need, and leave the rest.’ It’s all very ecumenical and friendly, which plays well for an audience that is expecting “healers” who are “open-minded.” Just as ‘all paths lead to the same God,’ all forms of woo are the same thing.

    Till you get into the details, and start pitting them against each other. Religious war.

  14. #14 bob
    March 4, 2009

    I don’t remember what the controversy between her and some skeptics was back in the day (it was covered on the SGU podcast), but I remember being really turned off by her. I see why now. Talk about sensationalistic (read: obnoxious) journalism. Is she trying to stir the pot to keep her job? Science journalists are getting axed all over the place, and that’s the only reason I can come up with to explain this.

    That, or she’s just an ass, of course.

  15. #15 mhwag
    March 4, 2009

    Begley is another pro-Obama shill. Any group that is concerned about long-term results of his policies, in this case physicians concerned about CCER, is dismissed. This is obvious from her own words:

    >>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” (CER), which is receiving $1 billion under the stimulus bill President Obama signed. CER means studies to determine which treatments, including drugs, are more medically and cost-effective for a given ailment than others.

  16. #16 Harry Eagar
    March 4, 2009

    If I were you, I’d avoid categorizing anti-science in conservative-liberal terms. I live in one of the world epicenters of woo, and the correlation of medical woo and liberal-progressivism is near 100%.

    I’m not saying there aren’t antiscience conservatives where I am (the largest church is Assembly of God), but just about all the noisy political liberals are also pushing qi, feng shui, magic rocks etc.

    Being an ignorant moron is unrelated to politics.

  17. #17 Ryan Biggs
    March 5, 2009

    Hilarious. She writes an article accusing doctors of being weak on science, and opens the article with the words “thank God…”

    Maybe she should pray to her invisible man in the sky for CCER.

  18. #18 LC
    March 6, 2009

    Orac,
    I think – in a less inflammatory manner than Begley’s column – you hit the central theme of her piece right here:

    [quote]
    Another problem, as I have pointed out before, is that most physicians are not trained in the scientific method, at least not very well. They truly do not know how to separate the wheat from the chaff, and are easily swayed by anecdotal evidence, be it their own “personal clinical observations” (shades of Dr. Jay!) or those of their colleagues, not realizing how easily anecdotes can mislead and how easily a series of anecdotes in a practice or region can lead to groupthink.
    [end quote}

    I belong to a huge HMO and have taken more drugs than I care to think about for “off-label” uses based, as far as I can tell, on undocumented personal experience, anecdotes, etc.

    I suggested to my physician that, given the size of the HMO (millions of patients), if it had an electronic database of all patients, medicines given, outcomes (effective, ineffective, side effects, etc.), other meds, basic health characteristics, standard data mining techniques could be used to tease out which drugs were most likely to work for which patient populations, which were most likely to have negative side effects, and neg. interactions between meds, etc.

    His response to me: I was “unique”. There is no way some of the trial-and-error (with me as the guinea pig) could be even lessened let alone removed from the system. I didn’t pursue the conversation further; I’d have had more luck talking to somebody at Google or Sense Networks (which is building consumer profiles from GPS & cell phones).

    I say this as the child of a doctor and the sibling of a nurse practitioner: I’d be more than willing to risk the potential downsides of a CCER if it would compensate for what you accurately portray as what seems to be an endemic lack of appreciation for the scientific method among physicians.

  19. #19 Kathleen Seidel
    March 8, 2009

    “What happened is that the procedure had started in a few centers, and it spread like wildfire through a combination of patient word-of-mouth, some of which was stoked by advertising by surgeons looking to distinguish themselves from the pack..”

    This sounds similar to the manner in which autism treatment fads proliferate — at Defeat Autism Now! and Autism One conferences, within Internet newsgroups, and by individual doctors with an entrepreneurial bent who establish or join those newsgroups, adopt the role of resident expert, dish with and grandstand before their potential clients, and disparage their competitors.

  20. #20 Dr Benway
    March 8, 2009

    I suggested to my physician that, given the size of the HMO (millions of patients), if it had an electronic database of all patients, medicines given, outcomes (effective, ineffective, side effects, etc.), other meds, basic health characteristics, standard data mining techniques could be used to tease out which drugs were most likely to work for which patient populations, which were most likely to have negative side effects, and neg. interactions between meds, etc.

    This is where I feel we need to start.

    Before we add incentives to practice guidelines –an intervention– we ought to describe what’s happening now, what’s being prescribed for what, how that’s going, and so on.

    Description is a complicated problem in its own right. Every variable costs money. Figuring out the variables worth tracking and how best to track them will take a little time.

    If I were in charge, I’d like to fund a variety of pilot programs concerned with tracking, aggregating, and presenting healthcare data in meaningful ways. Out of that I’d hope to learn ways to aggregate data across programs for greater statistical power.

    In short: I think we need systems that help us observe current practice before we start trying to modify current practice.

  21. #21 Skeptigirl
    March 9, 2009

    Hit a nerve, Orac?

    I’d like to write a counter article on the poor quality of science reporters. I think I’d be better sticking to the facts.

  22. #22 BJ,MD,JD
    March 14, 2009

    As I have always said, “There is a difference between the art of medicine and the science of medicine.” In my experience, patients prefer their physicians to be well versed in the art of medicine.
    BJ,MD,JD

  23. #23 Jonathan Blaze
    March 15, 2009

    Thank god Begley is brave enough to speak out against the medical profession, or as I like to call it, the Medical Mafia. Our medical system has become completely corrupted by greed. Doctors love to hear about the costs of health care going up, because it just means more of that money in their already overstuffed pockets. And now, doctors are scared that the government will expose their fraudulent practices for what they are. Of course they’re going to resist any oversight by trumping out every scare tactic in the book. But I don’t think the people are going to fall for it anymore.

    But what happens when we let doctors self-regulate? We get the broken system of today. We get lobbying juggernauts like the AMA whose sole purpose is to protect doctor salaries by artificially limiting the supply. We get unnecessary surgeries which probably harm patients while fattening the doctor’s pockets, such as the back surgeries mentioned in Begley’s article. We get doctors financially raping their patients, bankrupting them with over-inflated medical bills, many of which probably went to tests that doctors knew were unnecessary in the first place. Meanwhile doctors are buying more vacation homes and adding more Lexus SUVs to their fleets, while middle-class folks go homeless to pay bills.

    It’s funny how doctors like to trump the phrase “Do no harm”. While they might not be doing physical harm, bankrupting their patients with astronomical medical bills can do A LOT MORE HARM in the long run. But I guess doctors conveniently ignore this. They’ve had it drilled in their heads that DOCTOR=MONEY, so that is the path they choose. Patients be damned.

    Thank god the Obama administration is finally calling for oversight. It’s time to dismantle this corrupt system and build a new one, one where greed doesn’t come before health.

  24. #24 Chris
    March 15, 2009

    Well that was certainly a fact free rant.

  25. #25 lgmd
    March 29, 2009

    There are many physicians working at the front lines of health care delivery that embrace both the wellness model and clinical outcome based science. In many cases they have chosen their specialties because they consider understanding medical science an essential part of their professionalism and hold ethical decision-making a higher priority than financial profit. Seems obvious, but it may inform arguments that consider the middle ground in this debate negligible. Certainly, generalization, sensationalism and vilification of physicians is less likely to lead to the improved health status all parties seem to want to argue for.

  26. #26 Dr Benway
    March 29, 2009

    Hi Igmd,

    Buzz words like “wellness model” smell like marketing bullshit to me.

    Here’s my model: we figure out the risks and benefits of some intervention, then base our recommendations on that.

    I call it the “what is true” model. It kick’s the wellness model’s ass, then steals its lunch money.

  27. #27 ozdere
    December 7, 2009

    Hilarious. She writes an article accusing doctors of being weak on science, and opens the article with the words “thank God…”

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