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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."
I bet next they give mandatory prostate exams to women too!
"Infecting minds with my own memetic virus, one post at a time." Ultimape
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.
... 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.
In 1999 Merenstein examined a healthy 53-year-old man who showed no signs of prostate cancer. As he had been taught, Merenstein explained
This game will waste your life. Don't clicky!
... 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.
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?
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
The quote I like best is: "What do you call 'Alternative Medicine' that works?" "Medicine"
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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.)
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?
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?
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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.
Are agnostics skeptical of unicorns too?