5 ms·

Over the years I've practiced medicine the idea of "evidence-based" care has had its ups and downs. Part of the problem lies in the question of what is "eviden

Over the years I've practiced medicine the idea of "evidence-based" care has had its ups and downs. Part of the problem lies in the question of what is "evidence". From what I've seen, heard and read, the question is broader than pharmaceutical research though that's certainly an important element. The evidence literature spans making diagnoses, applying drug and non-drug therapies, deciding what is a successful outcome of treatment, etc. What I see is that clinicians are quite willing to use relevant and effective evidence-based methods. One problems applying evidence to real-world practice arises out of the aggregate bases of evidence. Even if evidence-based approaches could work in typical cases, many patients vary enough from norms that following evidence-based recommendations doesn't work. Furthermore it shouldn't be surprising when low-quality evidence gains corporate or governmental backing. When such promoted "standards" defy clinical observation it tarnishes the idea of evidence-based practice. An example is fairly recent recommendations that men over 70 shouldn't have routine PSA lab tests. Urologists will tell you about the hundreds of men they see with early stage prostate cancer detected by periodic PSA tests. Following the "evidence" would result in far more deaths and disability so it's ignored. As the article points out corruption of "evidence-based medicine" has destroyed much of the promise the idea once held. Insurers, pharma houses, governments contribute to abuse of evidence to serve their own agendas. No doubt some fraction of practitioners have added to problems and that needs to be halted. But IMO regulators are quick to point fingers at all clinicians for failures of health care systems. Rather most providers would prefer to avoid corrupt "evidence" whereas real evidence is welcome to workers toiling in the trenches.

wolverine876 5y ago
Thanks for sharing your perspective. > An example is fairly recent recommendations that men over 70 shouldn't have routine PSA lab tests. Urologists will tell you about the hundreds of men they see with early stage prostate cancer detected by periodic PSA tests. Following the "evidence" would result in far more deaths and disability so it's ignored. Isn't that how any system works - the rules provide guidance (with some teeth), and the people working hands-on apply their judgment? I recently was reading about the US Army's process. Many think of the military as highly regimented, but the US Army encourages - in fact, requires - subordinates to ignore orders that don't apply to their current situation; they are required to fulfill the 'commander's intent'. Only broken, authoritarian or totalitarian systems try to apply the theoretical centralized control to practice, where it is so rigid that it is bound to fail at scale (like another army in the news, apparently). What central authority is intelligent enough, has the information for, and the vision for anticipating every situation now and in the future, knowing the best solution, and writing rules for it?
- jrapdx3 5y ago
  Yeah I spent a couple of years in the US Army, albeit a long time ago. There were many rules and directives, a lot it was incredibly picky with minuscule impact and soon forgotten. There was an art to divining what was really important and what wasn't. In medicine today it's sort of similar, a lot of rules are propagated by bureaucratic minds. Sometimes it's just annoying, other times a big headache. On rare occasions such rules actually makes sense. The problem with rules like the one I cited is the risk that it will be enforced. This can happen in institutional settings like large clinics, a health care system or government agency. No set of rules or guidelines will be airtight and completely defensible. Yes, we're duty bound to act on the basis of reason and good judgement. However when rules are generated that are out of touch with reality there's a risk that regulatory entities, insurers, etc., will pick up that ball and run with it. Impediments to practicing according to one's best medical judgement are ubiquitous. One is insurance company rules requiring preauthorization for medications, even many generics. Can't tell you how many hours me and staff have spent knocking this around. Of course delayed treatment affects patient well-being. Ironically 95% of the time the meds I intended to prescribe were eventually approved anyway. Having to play the game accomplished nothing of value for anyone. You ask "What central authority...?" Of course, central authorities don't know the best solutions, often enough not even passable solutions to problems. Too many rules are as dangerous as not enough rules. I believe developing rules via "bottom-up" methodologies would produce rule sets with minimum necessary restriction and conceivably could even be productivity enhancing. I'll be quiet very soon, but I'm reminded of a patient encounter. A man was in my office talking about conflicts at work re: a micromanaging supervisor. It was a group of PhD-level software engineers. I was thinking, do these people even need "supervision"? Shouldn't they be trusted? Trustworthy professionals can be relied on to do their jobs. Sure, keep an eye on work quality, allow the track records to speak for themselves.
  - wolverine876 5y ago
    The problem is our politics - clearly our health care system needs fixing. But nobody chooses to act on politics, and the obvious obstructions to progress. > I'm reminded of a patient encounter. A man was in my office talking about conflicts at work re: a micromanaging supervisor. It was a group of PhD-level software engineers. I was thinking, do these people even need "supervision"? Shouldn't they be trusted? Trustworthy professionals can be relied on to do their jobs. Sure, keep an eye on work quality, allow the track records to speak for themselves. Generally, yes, good management is knowing who to trust, and putting them in a position to succeed. But the original bias, of course, is toward ourselves. They/we are still human, we still put our pants on one leg at a time. Just because we are highly skilled in something, doesn't mean we have good judgment in other ways, we are motivated, not distracted, biased in other ways, etc. Plenty of very successful people do god-awful stupid things.

wolverine876 5y ago

Thanks for sharing your perspective. > An example is fairly recent recommendations that men over 70 shouldn't have routine PSA lab tests. Urologists will tell you about the hundreds of men they see with early stage prostate cancer detected by periodic PSA tests. Following the "evidence" would result in far more deaths and disability so it's ignored. Isn't that how any system works - the rules provide guidance (with some teeth), and the people working hands-on apply their judgment? I recently was reading about the US Army's process. Many think of the military as highly regimented, but the US Army encourages - in fact, requires - subordinates to ignore orders that don't apply to their current situation; they are required to fulfill the 'commander's intent'. Only broken, authoritarian or totalitarian systems try to apply the theoretical centralized control to practice, where it is so rigid that it is bound to fail at scale (like another army in the news, apparently). What central authority is intelligent enough, has the information for, and the vision for anticipating every situation now and in the future, knowing the best solution, and writing rules for it?

jrapdx3 5y ago
Yeah I spent a couple of years in the US Army, albeit a long time ago. There were many rules and directives, a lot it was incredibly picky with minuscule impact and soon forgotten. There was an art to divining what was really important and what wasn't. In medicine today it's sort of similar, a lot of rules are propagated by bureaucratic minds. Sometimes it's just annoying, other times a big headache. On rare occasions such rules actually makes sense. The problem with rules like the one I cited is the risk that it will be enforced. This can happen in institutional settings like large clinics, a health care system or government agency. No set of rules or guidelines will be airtight and completely defensible. Yes, we're duty bound to act on the basis of reason and good judgement. However when rules are generated that are out of touch with reality there's a risk that regulatory entities, insurers, etc., will pick up that ball and run with it. Impediments to practicing according to one's best medical judgement are ubiquitous. One is insurance company rules requiring preauthorization for medications, even many generics. Can't tell you how many hours me and staff have spent knocking this around. Of course delayed treatment affects patient well-being. Ironically 95% of the time the meds I intended to prescribe were eventually approved anyway. Having to play the game accomplished nothing of value for anyone. You ask "What central authority...?" Of course, central authorities don't know the best solutions, often enough not even passable solutions to problems. Too many rules are as dangerous as not enough rules. I believe developing rules via "bottom-up" methodologies would produce rule sets with minimum necessary restriction and conceivably could even be productivity enhancing. I'll be quiet very soon, but I'm reminded of a patient encounter. A man was in my office talking about conflicts at work re: a micromanaging supervisor. It was a group of PhD-level software engineers. I was thinking, do these people even need "supervision"? Shouldn't they be trusted? Trustworthy professionals can be relied on to do their jobs. Sure, keep an eye on work quality, allow the track records to speak for themselves.
- wolverine876 5y ago
  The problem is our politics - clearly our health care system needs fixing. But nobody chooses to act on politics, and the obvious obstructions to progress. > I'm reminded of a patient encounter. A man was in my office talking about conflicts at work re: a micromanaging supervisor. It was a group of PhD-level software engineers. I was thinking, do these people even need "supervision"? Shouldn't they be trusted? Trustworthy professionals can be relied on to do their jobs. Sure, keep an eye on work quality, allow the track records to speak for themselves. Generally, yes, good management is knowing who to trust, and putting them in a position to succeed. But the original bias, of course, is toward ourselves. They/we are still human, we still put our pants on one leg at a time. Just because we are highly skilled in something, doesn't mean we have good judgment in other ways, we are motivated, not distracted, biased in other ways, etc. Plenty of very successful people do god-awful stupid things.