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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."
... 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.
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.
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.
Data is not the plural of anecdote.
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.
Money is the root of all evil?
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.
#fuckbeta #iamslashdot #dicemustdie
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.
It is a miracle that curiosity survives formal education. - Einstein
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.
You are welcome on my lawn.
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
Light a fire for a man and he'll be warm for a day. Light a man on fire and he'll be warm for the rest of his life.
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.
Are you adequate?
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.
You're right about that not being the relevant question. The relevant question is:
Why is this included in an ECONOMIC STIMULUS PLAN?
3 things about computers: they're alive, they're self-aware, and they hate your guts.
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.
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.