There has been a flurry of news relevant to science-based medicine in the last week – more than enough to keep a bevy of bloggers busy. More important than the individual news items themselves is the striking pattern they bring into focus when viewed together – the growing and pernicious double-standard between mainstream medicine and so-called CAM.
Begley vs Doctors
Science editor Sharon Begley wrote an interesting piece in Newsweek with the provocative title: Why Doctors Hate Science. I was not particularly impressed with the article – it took a rather narrow approach to a complex problem and ran with it. She writes:
It’s hard not to scream when you see how many physicians, pharmaceutical companies, medical-device makers and, lately, hysterical conservatives seem to hate science, or at best ignore it. These days the science that inspires fear and loathing is “comparative-effectiveness research” (CER), which is receiving $1 billion under the stimulus bill President Obama signed. CER means studies to determine which treatments, including drugs, are more medically and cost-effective for a given ailment than others.
I certainly agree that opposing or ignoring mainstream science is a serious problem, especially within healthcare. Begley points out, correctly, that there is great disparity among how physicians manage many ailments. Her interpretation of this fact, however, is far too simplistic to be helpful. She concludes that – well, doctors hate science. If they were listening to the science they would all be practicing the same way. She further argues that doctors resist initiatives like CER because they resent attempts at controlling their practice, or limiting their profits, even with science. They would rather shoot from the hip.
I agree that this is one part of the picture. It is also true, however, that there is great disparity among doctors in terms of their attitudes toward the relationship between scientific evidence and practice. There are those who are rigorously and proactively science-based. At the other end of the spectrum there are those who take a decidedly anti-scientific and anecdotal approach to medicine. While most physicians are somewhere in between.
The real question is – what is keeping most doctors from being more rigorously evidence-based. Begley suggests it is culture. However the institution of evidence-based medicine (EBM) is premised on another explanation – that the problem is simply that medicine has become so complex and is changing so quickly it is simply very difficult for health care practitioners to have access to the latest scientific information at the point of patient contact.
In my experience most physicians actually want to be science-based, and they think that they are. They fall short because they lack the systems and resources to keep current. Some may be lazy too, but again that is a spectrum we are all on. No one is tireless.
I also think that some physicians are just poorly trained, and develop bad habits of thought they carry throughout their careers. Physicians need to be taught more uniformly to think more critically, scientifically, and skeptically.
Another factor not mentioned by Begley is that for many medical decisions the available data is ambiguous. Regions develop their local standards of practice because ambiguous data allows them to. Where the data is more solid variation in practice decreases (I have seen this happen many times in my speciality). And another salient factor is that disease rates actually vary significantly from region to region, and this partly explains differences in procedure and treatment rates.
Not only has Begley oversimplified her diagnosis, she recommends a specific remedy as if it is the only solution – CER. Last week Val Jones wrote on SBM about the same problem in health care and recommended a completely different solution. To summarize, CER is a top-down approach – you have a committee of experts decide what the science says about a specific medical situation and then impose practice standards from above.
Val was recommending a bottom-up approach – improve physician education about SBM and their access to needed information. She argues, and I agree, that physicians do not have to be forced by committee to do the right thing. If they know what the right thing is they will tend to do it on their own.
I actually think that both methods should be blended. For certain medical situations the evidence strongly supports certain interventions and their application is fairly straightforward. For those situations top-down practice standards make sense, to maximize compliance with best practices. This could still leave room for individualization of care but would make the default management the EBM standard. But for many other medical interventions the bottom-up approach is probably best.
It seems clear that whichever method is preferred, improved education and access to critical information is going to be very important to improving health outcomes and cost effectiveness in the future, and that information technology must play a central role.
Begley vs Tom Harkin
Here is where the double standard comes in. Everyone seems to agree that we need to make efforts to increase the degree to which doctors are science and evidence-based in their practice. We may disagree as to the causes and the best solutions, but everyone agrees that science is the answer. Some are even willing to put science-based doctors on a very short leash in order to make them even more science-based.
However, at the same time there is a completely separate conversation going on, as if it is taking place in a parallel universe, promoting the notion that so-called alternative practitioners should be freed from the shackles of scientific regulation.
David Gorski and Peter Lipson both wrote entries recently discussing Senator Tom Harkin’s hearing in which he invited some of the luminaries of the CAM movement to explain how healthcare reform can be hijacked to promote ideology, faith, sectarian practices, and the freedom to pursue profits unfettered by regulation over science-based medicine (OK, they didn’t put it exactly like that, but I think that is a fair summary). I won’t go over this terrain again, as David and Peter covered it nicely.
In short, Harkin is upset that his beloved CAM modalities are not meeting the standards of science, despite being given every unfair advantage and special consideration. Rather than concluding, as I think is reasonable, that this is because these CAM modalities do not work (which probably has something to do with why they are CAM in the first place), he concludes that they should be promoted and “integrated” into healthcare anyway.
It seems that when dealing with mainstream medicine the mantra is more and more regulation, oversight, and enforcement of standards. However, when dealing with so-called alternative medicine the mantra is more freedom and less regulation.
I think a meaningful discussion of the relative roles of top-down regulation vs bottom-up education in improving science-based medicine is useful and even necessary. I have my opinions, but no one really knows what the best balance of these two approaches will be. I therefore agree with those who call for outcome measures to monitor various efforts at improving quality control in medicine, so we can see what actually works.
But these efforts must be universal. They should not be applied to one subset of the healthcare industry and not to another. Yet the CAM movement has been amazingly successful at promoting a double-standard, where they are free from all such regulation and quality control.
If we are to have an honest conversation in this country about quality control in medicine, these two parallel conversations need to be merged. They can no longer continue to exist side-by-side in parallel universes.
Next week I will write about another double-standard: pharmaceuticals vs supplements, and the new GAO report on supplement regulation by the FDA.