Health Care Reform: The Difference Between Rationing and Rational

Some advances do not require testing because they are obviously wonderful: antibiotics for infections that are otherwise fatal, some forms of trauma surgery, kidney dialysis and transplantation, etc. Other advances seem miraculous because they make sense but how do we know we're not being fooled as we often were in the recent past:

At mid-century we removed the inflamed tonsils from most young children who had persistent upper respiratory infections in the winter and thought we were heroes because they were spared tonsillitis come next winter. Now we know that they outgrow such with their tonsils in place. And remember the tubes in the ears? The antibiotics for every inflamed ear drum? Gone with the data.

At mid-century we were removing wombs and teeth and gall bladders from patients with rheumatoid arthritis to get rid of the evil focus of infection. Now we know we only offered them the possibility of surgical complications.

Many of the drugs that made sense to treat heart failure and asthma in 1970 turned out to be useless or harmful by 1990.

And much more...

Today we know that our best guess and our best theories can lead us astray. Today we educate every medical student to know to ask, and to know how to ask for the evidence that interventions actually work. Today, an enormous investment is made is doing the studies that define the evidentiary basis for all new pharmaceuticals before FDA licensure. Today, an enormous investment is made by industry to provide the evidence that their pill or device is better than the competition's.

Thousands and thousands of papers appear each year, varying in scientific quality, varying in the patient groups studied, varying in the intervention studied. Many of us who practice medicine feel compelled to analyze this information as it pertains to the problems of our patient.

The task of defining the evidentiary basis of medical practice has such scope that my profession has fostered not-for-profit, independent organizations devoted to the exercise. Some of the most influential are the U.S. Preventative Services Task Force, the British National Institute for Health and Clinical Excellence, and the ACP Journal Club.

The granddaddy is the Cochrane Collaboration. The Cochrane Collaboration was founded in 1993. Based in Oxford, England, it is a highly structured, international collaboration of thousands of volunteer scientists organized into review groups based on particular topics. These groups produce and disseminate systematic reviews of the literature on the efficacy of healthcare interventions; thousands are already available, more come every year, and older reviews are updated.

Informed Clinical Decision Making

Robert McNutt, one of the editors of the Journal of the American Medical Association, wrote a brilliant essay on how we as patients should advocate for our own health care. He, and I, believe we are each the captain of our own ship. Our physician is the navigator. Our physician owes us more than clinical judgment, which is wisdom derived from the accumulation of clinical experiences. We are owed a statement as to whether there is scientific evidence for benefit, and if so how much benefit? Enough so that it is meaningful to me? If there is no evidence for benefit, was the intervention studied so adequately to support a statement of "there is no benefit"?

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