In Copyright Since September 11,
2000
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The Misuse of Evidence-Based Medicine
November 14, 2007
"Evidence
Based Medicine" was the original dream of an accountant in England
named Archie
Cochrane. He decided that if all of the
medical articles in the world could be
synthesized into pure
knowledge - and weighted toward levels of certainty - then out would
come a central logic of what to do in most or all
situations. And so the Cochrane
Collection was created
and is ongoing on the Internet.
To itself it is fairly pure and unbiased - like a glacier on the top of
the mountain.
England was the first to try to manipulate
the collection to the government's supposed benefit and
decided that at York there
would be clinical testing or validation of the Cochrane
evidence. They immediately picked out those topics
where they might save money - so that less care could be given if
possible to so prove. Pure knowledge is budget neutral -
creating more care for some problems and less for others. But
to no one's surprise the government paid for and got back what
it wanted - minimalist care.
The actual term "Evidenced Based Medicine" or EBM
was dreamed up in the
Family Practice Department of McGill University.
They have conceded that what they really wanted to create is "Expert
Absent Medicine." Clearly it would be cheaper to punch up the
computer than asking real experts. Instead, the practicing
physician was to become dependent on reviews of reviews. The
physician - burdened by medical school to be free thinking and
challenging to the changing world of science - could now simply leave
the thinking to others. In fact, there is even a bizarre
approach to give every symptom a diagnostic weight so in combination
the physician analysis is no longer needed.
The rivalry between narrative
medicine (the careful
interview of the patient and building up of diagnostic clues) is still
championed by Harrison's Textbook of Medicine.
The rival Cecil and Loebe has allowed its
diagnostic chapter to be written in the EBM style of weighing symptoms
computer style. Harrison acknowledges the advances of
evidence but still finds the most complex of medical skills - a good
interview - to be best governed by and then taught by
experts. In terms of our glacier, we are starting to work our
way down to the forest of animals and their discharges into the
mountain streams.
HMOs decided that EBV if yoked to their
goals of "the
less we do the more money we make" (Kaiser CEO to
Nixon summary in SICKO),
then the public would have no legal defense against being victimized by
disease. It goes along with illness being life style created
so being sick is about the same as being bad. Thriving
is something joggers do each morning, not really a promise of a prepaid
health plan. Experts - on the Kaiser
Website - were once pictured as old men with simply the halos
of balding hair. After I pointed that out, the Website
morphed.
To see the "malignant heart" approach used
by HMOs in blocking care, one needs to hold side by side the original
evidence against the "evidence" within the secret
Guidelines and Pathways of the HMO. The American
Diabetes Association, for example,states that all couch
potato types need to be tested for diabetes rather than
waiting until a few show up suddenly needing dialysis.
Kaiser carefully changed this recommendation so that such folks would
not be tested in a chart that almost matches but has been fudged toward
less care. At the same time the for profit Permanente
physicians carefully invested in dialysis ventures.
In such a case, all risk is shifted to
patients. Disease become the internal ovens that cook from
within. In fact, the perfect art of HMO EBM is to catch
diseases right at the point of dialysis or hospice - as new federal
money suddenly pours in. If cancer is diagnosed
just late enough, it can be declared hopeless just as it is
found. legally, the HMO's care cannot be challenged if the
chance of cure drops below 50%. And the medical
records are spoiled anyway by Risk
Management - so who
cares?
Perhaps the easiest example that one can
follow of the perversion of EBM - somewhere near the polluted delta
where swimming is not allowed - is that which Kaiser produced by "partnering" with the
Communicable Disease Center for anthrax diagnosis. Kaiser stated that a low oxygen level was a
good screen for anthrax. The CDC explained that
Anthrax - though inhaled - often bypasses the lungs on the way to
mediastinal involvement and shock; low oxygen would only be a too late
sign. Kaiser intent in its release of a protocol was to cover
up missing an anthrax patient and actually set up to NOT
catch the next case.
Yet, for Kaiser - on their Permanente
Medicine Map - the only way to the "Sustainable Future" for the fleet
of Permanente (pictured as a group of ships) is through the
straights of EBM. This is the pathway for each partner
physician to end up with a millionaire's pension, e.g. $15,000 a month
plus social security. But the partners can never tell the
above tale because the pension is all potentially gone if the same
physicians do not support the HMO and its expansion (yes - in
writing). This
is the great "gag" clause.
Like all good ideas that get translated
into profit, evidence based medicine is now so contaminated with
dysinformation that it is dangerous. With EBM nurses will
hold out in HMOs to be practitioners - though only RNs with no
diagnostic training - and withhold antibiotics from all but those
yelling for them. And since it is "evidence," it does not
matter if it is given out by the least qualified. The patient
history - 90% of diagnosis - is tossed out the window as time
consuming. After all patients are simply "the worried well" using up health
dollars instead of eating broccoli.
Judges will find themselves weighing competing "evidence" journals -
medical experts no longer needed in court.
I sound like the near extinct physician
eagle flying over the
canyons of the past. But then I am comforted to know that ER
physicians in general have remained skeptical about this new panacea of
information. In fact, the lead ER journal noted that by the
time
"evidence" has gone from the source to the frontline it has passed
through 11 prisms of value judgment. The "retrospectoscope"
is not as clear
as we had hoped.
When I get sick, I will look for an
expert. That expert will be able to quote all the current
lead articles but will also bring to bear experience. And,
yes, his or her white coat will really stand for the oath of patient
loyalty. For that moment in time, I will be the north
star around which the medical world revolves. I
will have a champion willing to take on the dragon of
disease. I will not be a stepping stone to the expert's
retirement plan.
Sorry, Archie. You had a good
idea. We need to perfect the collection and selection of
knowledge. But there are white coats and green
coats. Until it becomes profitable to give superior care,
"evidence" is often just the pathway to doing nothing.
Chuck Phillips, MD, FACEP
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