Sunday, April 25, 2010

Evidence-Based Health Care

Crommunist posted a thoughtful piece last week in which he considers who should be in charge of an individual’s health care – the individual, or the physician. This got me thinking about the subject of evidence-based medicine. Crommunist examines the specific topic of a new and relatively untested method of treating multiple sclerosis; I will take a general tack, and add just a few additional thoughts.

The salient point, I think, from Crommunist’s post is that doctors, not patients, should be in charge of an individual’s health care. He writes:
When you’re sick, you have only one goal: getting better. Millions of years of evolution have hard-wired a strong survival instinct into all living species, and human beings are no exception. People suffering from disease and their families are willing to do just about anything for a chance at recovery, and logic plays nearly no role in the decision-making process.
Riding shotgun with these thoughts is the fact that a sick individual now has access to an overwhelming wealth of medical information via the internet. While this information may be helpful as a reference, there’s no way for the individual to discern how it actually applies to their medical concerns as he lacks the knowledge an experienced, licensed clinician has to tie the information to a medical concern. So, what happens at the individual level is that a person may make a “self-diagnosis”, connecting gathered information in ways that a physician might not. This may lead the individual to pressure his or her doctor to prescribe tests or drugs that may not be necessary or appropriate. And indeed, the doctor may feel obligated to offer testing and drugs unsolicited in order to guard against possible malpractice suits.

The net effect of unnecessary testing is that medical care costs us far more than it should. For those of us fortunate enough to have health insurance, it’s easy to request or acquiesce to unnecessary medical services as we’re not paying full price. Overuse of these services, however, can only drive up the cost of insurance. So, we do actually pay a hidden cost for these services while making insurance more costly for those that can least afford it.

What we are faced with here is a systemic dysfunction. While individuals should be informed about their health, the physician should be directing care, not the individual. Additionally, we need to tackle other problems such as continuity of care, health records reform, malpractice protections, etc. This article from AARP suggests some sensible reform possibilities, along with steps a patient can take to make better decisions about their own health care.


  1. Thanks for the link, Chris. It's simultaneously encouraging and frightening that patients have unprecedented access to medical information. Shows like House and ER have de-mystified doctors, which can be a positive thing, but they're definitely explicitly trained for medical treatment whereas patients aren't quite as knowledgeable as they think. There's probably a million anecdotes of a patient making a better call than a doctor, but nobody talks about the times when MDs make life-saving calls over patient equivocation (or more tragically, when patients overrule their doctors and die as a result).

    There's quite a bit of discussion in the priority-setting and decision-making literature (part of my job) about this exact issue.

  2. Probably a point I should clarify, as I didn't do it in my post.

    I don't think physicians should have 100% control over a patient's care without any input. I was approaching this issue from a policy perspective - what types of things do we fund, what tests do we make available? These types of decisions require patient and physician input but should not be dictated by either. The patient is responsible only to him/herself, and the physician is responsible only to the patient in front of him/her at that moment. Policy decisions should be made based on evidence by groups of people who consider the health of the system as a whole, rather than any one patient. It seems heartless not to prioritize patient suffering, but someone has to be thinking about the next patient.

    Anyway, thanks again.

  3. I agree that these days there is much too much information for patients to wallow in. Sites like 'Wrong Diagnosis' and 'WebMD' can be frightening and very misleading. A bloody nose that is caused by dry winter air can cause a patient to consider a blood clot in the brain and demand a MRI. The doctor has to make the decision now as to satisfy the patient by playing into their fears or comfort them and deny the testing the patient is obsessing about.
    On the other hand, many people have things going on and they just don't feel right and doctors haven't a clue what to do about it so they do nothing. The patient then goes on an information gathering war path to figure out what MUST be wrong with them - and gain support of thousands of other "undiagnosed" people on these info gathering sites. It makes the patient feel vindicated and adds to distrust between the patient-doctor relationship.
    I've been on both ends of this spectrum. I was diagnosed with Graves Disease and Diabetes with in two weeks of each other after feeling horrible for months. My primary doc didn't do any blood tests and sent me on my way. A nurse practitioner listened and that resulted in my Dx. Which in some way actually gave me credibility to my primary doctor.
    I know I've gone way off topic here...but my point is...there has to be a balance. A good relationship with your doctor is key.

  4. Thank you both for your comprehensive responses. Re-reading my post, I realize the cursory treatment I gave the subject was even more cursory than I intended, and you've called me on it! I realize that I come off sounding like I think the issue is black and white when I know from experience it most definitely is not. I will follow up with another post clarifying my thoughts as time permits.

    I'm always happy to promote good writing and good reasoning!

    I will address in depth your second comment in my follow-up.

    I will address your thoughts as well in terms of continuity of care. And you're quite right. "A good relationship with your doctor is key."

    Thanks again!