From: olivercrangle2@gmail.com   
      
   Health Care Myth Busters: Is There a High Degree of Scientific   
   Certainty in Modern Medicine?   
   Two doctors take on the health care system in a new book that aims to   
   arm people with information   
   By Sanjaya Kumar and David B. Nash  | Friday, March 25, 2011 | 28   
   DO DOCTORS HAVE GOOD DATA?: An excerpt from Demand Better! Revive Our   
   Broken Health Care System by Sanjaya Kumar and David B. Nash   
   Image: Second River Healthcare Press   
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   Editor's Note: The following is an excerpt from the new book Demand   
   Better! Revive Our Broken Health Care System (Second River Healthcare   
   Press, March 2011) by Sanjaya Kumar, chief medical officer at   
   Quantros, and David B. Nash, dean of the Jefferson School of   
   Population Health at Thomas Jefferson University. In the following   
   chapter they explore the striking dearth of data and persistent   
   uncertainty that clinicians often face when having to make decisions.   
      
      
   Myth: There is a high degree of scientific certainty in modern   
   medicine   
      
   "In America, there is no guarantee that any individual will receive   
   high-quality care for any particular health problem. The healthcare   
   industry is plagued with overutilization of  services,   
   underutilization of services and errors in  healthcare practice." –   
   Elizabeth A. McGlynn, PhD, Rand Corporation researcher, and   
   colleagues. (Elizabeth A. McGlynn, PhD; Steven M. Asch, MD, MPH; et   
   al. "The Quality of Healthcare Delivered to Adults in the United   
   States," New England Journal of Medicine 2003;348:2635-2645.)   
      
      
   Most of us are confident that the quality of our healthcare is the   
   finest, the most technologically sophisticated and the most   
   scientifically advanced in the world. And for good reason—thousands of   
   clinical research studies are published every year that indicate such   
   findings. Hospitals advertise the latest, most dazzling techniques to   
   peer into the human body and perform amazing lifesaving surgeries with   
   the aid of high-tech devices. There is no question that modern medical   
   practices are remarkable, often effective and occasionally   
   miraculous.   
      
   But there is a wrinkle in our confidence. We believe that the vast   
   majority of what physicians do is backed by solid science. Their   
   diagnostic and treatment decisions must reflect the latest and best   
   research. Their clinical judgment must certainly be well beyond any   
   reasonable doubt. To seriously question these assumptions would seem   
   jaundiced and cynical.   
      
   But we must question them because these beliefs are based more on   
   faith than on facts for at least three reasons, each of which we will   
   explore in detail in this section. Only a fraction of what physicians   
   do is based on solid evidence from Grade-A randomized, controlled   
   trials; the rest is based instead on weak or no evidence and on   
   subjective judgment. When scientific consensus exists on which   
   clinical practices work effectively, physicians only sporadically   
   follow that evidence correctly.   
      
   Medical decision-making itself is fraught with inherent subjectivity,   
   some of it necessary and beneficial to patients, and some of it flawed   
   and potentially dangerous. For these reasons, millions of Americans   
   receive medications and treatments that have no proven clinical   
   benefit, and millions fail to get care that is proven to be effective.   
   Quality and safety suffer, and waste flourishes.   
      
   We know, for example, that when a patient goes to his primary-care   
   physician with a very common problem like lower back pain, the   
   physician will deliver the right treatment with real clinical benefit   
   about half of the time. Patients with the same health problem who go   
   to different physicians will get wildly different treatments. Those   
   physicians can't all be right.   
      
   Having limited clinical evidence for their decision-making is not the   
   only gap in physicians' scientific certainty. Physician judgment—the   
   "art" of medicine—inevitably comes into play, for better or for worse.   
   Even physicians with the most advanced technical skills sometimes fail   
   to achieve the highest quality outcomes for their patients.  That's   
   when resourcefulness—trying different and potentially better   
   interventions—can bend the quality curve even further.   
      
   And, even the most experienced physicians make errors in diagnosing   
   patients because of cognitive biases inherent to human thinking   
   processes. These subjective, "nonscientific" features of physician   
   judgment work in parallel with the relative scarcity of strong   
   scientific backing when physicians make decisions about how to care   
   for their patients.   
      
   We could accurately say, "Half of what physicians do is wrong," or   
   "Less than 20 percent of what physicians do has solid research to   
   support it." Although these claims sound absurd, they are solidly   
   supported by research that is largely agreed upon by experts. Yet   
   these claims are rarely discussed publicly. It would be political   
   suicide for our public leaders to admit these truths and risk being   
   branded as reactionary or radical. Most Americans wouldn't believe   
   them anyway. Dozens of stakeholders are continuously jockeying to   
   promote their vested interests, making it difficult for anyone to   
   summarize a complex and nuanced body of research in a way that cuts   
   through the partisan fog and satisfies everyone's agendas. That, too,   
   is part of the problem.   
      
   Questioning the unquestionable   
   The problem is that physicians don't know what they're doing. That is   
   how David Eddy, MD, PhD, a healthcare economist and senior advisor for   
   health policy and management for Kaiser Permanente, put the problem in   
   a Business Week cover story about how much of healthcare delivery is   
   not based on science. Plenty of proof backs up Eddy's glib-sounding   
   remark.   
      
   The plain fact is that many clinical decisions made by physicians   
   appear to be arbitrary, uncertain and variable. Reams of research   
   point to the same finding: physicians looking at the same thing will   
   disagree with each other, or even with themselves, from 10 percent to   
   50 percent of the time during virtually every aspect of the medical-   
   care process—from taking a medical history to doing a physical   
   examination, reading a laboratory test, performing a pathological   
   diagnosis and recommending a treatment. Physician judgment is highly   
   variable.   
      
      
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