ACA Ruling and “One Sized fits All” Medical Care
For those of you that follow this blog, you know that it was only a matter of time before I commented on the ACA and the ACA ruling by the Supreme Court. Regardless of your personal politics, as a physician, I can see a few things I like and many things that are a serious problem for doctors and patients. For example, I like not having pre-existing conditions anymore and putting some rules around how insurance companies deal with patients. Having said that, one of the more concerning problems with the law is the “Independent” Advisory Panels who will study population based research data to try and figure out what gets covered and doesn’t. There is a part of the new book that deals with this particular issue of using traditional “frequentist” research to define strict protocols for treating unique patients. Here goes:
“One Size DOES NOT Fit All in Patient Therapy
Evidence Based Medicine (EBM) and frequentist studies are helpful, and often provide a strong foundation for developing and applying new therapies. However, when the concept is applied to medical research, it is more about what has been shown to work collectively for everybody than about what’s effective for the individual patient. In essence, it’s “one size fits all” research.
Applying data collected using the law of averages often doesn’t apply to individual patients. Let me give you a common sense example. A study looking at the average height or men in the US would find that it’sabout 5 foot 9.5 inches. If we tried to use that information to create one size fits all clothing, it would be a disaster. Observing any clothing store you would immediately recognize that clothes for men come in many different sizes. In fact some men are so large or so small that they need to go to specialty stores to buy their unusual sizes. This simple thought exercise captures our national EBM movement in medicine, an attempt to use empirical, reductionist medical research to play the law of averages to create “one size fits all” medicine.
Religion and EBM
There is a devout belief that EBM is the absolute cure for whatever ails medicine. Discussing EBM with a scientist or university physician can be like discussing religion with an evangelical. EBM has been with us as an evangelical type of movement for more than two decades, driven in large part by the vested interests profiting from EBM, namely large universities and the medical research industry. In large part, much of our pending health reform legislation is based on the concept that a whole nation of doctors using EBM to guide their decisions will save money and improve outcomes.
Not so fast, say some scientists.
In fact, the entire EBM quasi-religious movement has also been criticized as a huge plunge of faith down an expensive rabbit hole.A 2008 editorialbyCohenandHersh lays out the problems with EBM. These include empiricism, too narrow a focus, no practical evidence that it works, and challenges when applying EBM to the individual patient.
Empiricism is the huge leap of faith that evidence derived from experiments trumps all other types of knowledge. In medicine, this means that what we learn from experiments about a large number of patients is better than what doctors observe on the ground about what actually works in specific patients. This leads us to the second big sticky wicket of EBM- the very nature of medical scientific study is to narrow the focus of what’s tested and on whom, so much so that the information produced by many EBM studies may no longer important to the doctors seeing real patients. Third, while it’s assumed that arming doctors with empirical evidence will save money and improve outcomes, we have no evidence that evidence-based medicine will actually do this–just a blind-faith belief purported by the “true believers” that this will happen.
In summary, while our blind-faith reliance on EBM may help some doctors make better decisions about certain patients, it also alienates the individual patient. The individual in EBM is simply not important, as the law of averages rules the day.”