Jun 18 2009
I have a confession to make – it’s not easy keeping up with the other “Joneses” on this blog. My colleagues do a terrific job with thoroughly referenced analyses of key issues in medicine – and I sometimes struggle to think of topics that they haven’t already covered in more depth than I can. So today I asked my friends on Twitter if they had any suggestions for this week’s post.
One Twitter respondent asked me for my “perspective on the biggest barriers to better funding and adoption of science- based medicine.” As I contemplated that question, an experience leapt immediately to mind…
I attended a recent press conference held at a major Washington, DC think tank. An all-star cast was assembled, including Senator Baucus and Peter Orszag, to discuss the subject of comparative effectiveness research (CER). The most memorable part of the conference, however, was when one of the CER policy “experts” took the podium and actually said this (I’m going to paraphrase slightly):
The problem with science is that it’s too narrow. We’d have a lot more information to go on if we got rid of the narrow inclusion criteria in clinical trials. The exclusivity is not an irreversible flaw in the method – we just need to open up trials to larger groups of people of all kinds of different backgrounds so we can get better information.
Wow. Where to begin with that one? Amazingly, the man was not challenged about his point of view and is probably happily developing and shaping healthcare reform policy right now. Which brings me to my first “barrier” to better funding and adoption of science based medicine – a fundamental lack of understanding of the scientific method on the part of certain people who hold purse strings. If you think that this is a an anomalous point of view in Washington, please consider Senator Harkin’s recent arguments about the role of NCCAM as a “validating” agency for alternative medicine.
Now, in all fairness, there are certainly reasonable people in Washington who understand the importance of science and the basic tenets of the scientific method. But these people may be outnumbered and outgunned by those without science backgrounds when it comes to creating policy. So, from what I can see, the first barrier to adoption of science based medicine is a fundamental lapse in science education. How can one appropriately fund and adopt something they don’t understand? It’d be like asking a bunch of doctors to reform the legal system – something we recognize immediately as foolhardy. Still, no one bats an eyelash when people without any background in science or medicine work to reform healthcare. I don’t get it.
The second barrier that comes to mind is our human tendency to value personal experience over objective evidence. This is really, really hard to overcome. No one is immune from personal biases and scientists themselves have a hard time parting with beliefs that are misguided. For example, it seems intuitive that mechanically propping open an artery would be superior to just leaving it all clogged up – and yet, careful analysis suggests that stents (cardiac or renal) are not superior to medical management in many cases. When will physician practice behaviors change to reflect this evidence? Probably a decade.
Of course, experientialism is often left unchecked in consumer news, TV programming, and publications – where pseudoscience and an argument that “sounds good” becomes sufficient evidence to accept all types of information as fact. Some believe Oprah because she’s winsome – some listen to Jenny McCarthy because she’s attractive and passionate about motherhood. The experience that entertainers create has mass appeal, even while it’s often pure fluff or even outright harmful.
A third barrier to science-based medicine is economics. Good research is expensive, and definitive research is exorbitant. But beyond the incredible expense of carefully teasing out cause and effect in complex organisms like humans, there is the problem of financial incentives to put good research into practice. One person’s waste is another person’s income – and so there will always be industry and provider resistance to clear winners and losers in healthcare.
In summary, adopting evidence based practices in healthcare is difficult for many reasons. First, healthcare decision-makers often have insufficient science education to make informed decisions about health policy. Second, humans all have the tendency to lean on personal experience over objective evidence when it comes to making decisions – and consumer heart strings are often intentionally pulled for sales and marketing purposes. Third, economic factors introduce another layer of friction in science-based medicine implementation. There are no doubt many other barriers that I did not discuss in this post, so please feel free to add your thoughts below.
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