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Why hasn’t evidence-based medicine been made standard practice?

Posted Aug 04 2009 5:50pm

Robin Mancuso, in an op-ed piece for Modern Healthcare, believes that we are at a “historic juncture regarding healthcare” and points out that we must “pay providers for quality… [which] includes getting those with known conditions on an evidence-based treatment plan.” So what’s stopping us?

In this second entry, Dr. Seymour Handler, pathologist and guest blogger, addresses one of the main deficiencies in medical practice that contributes to cost inflation: evidence-based medicine. In his previous entry, Dr. Handler noted three factors influencing cost inflation. In this entry, he tackles why EBM hasn’t been made standard practice.

One of the most flagrant deficiencies in current medical practice is the relative lack of evidence-based medicine (EBM). It is only in the past 20 years or so that academics have progressively investigated this lack and have concluded that very little of what physicians do in everyday patient care, either diagnostically or therapeutically, has undergone the scientific scrutiny of statistically valid evaluation attesting to safety and yield. The New England Journal of Medicine (and other peer-review medical journals) regularly contains studies of commonly performed medical procedures demonstrating that the activities lack any patient care value. Unfortunately, the studies are too late, performed after tens of thousands (or more) of procedures have already been performed and which are everyday activities in medical practice. The lack of EBM should earlier have been addressed by random clinical trials (RCTs) in which a proposed new diagnostic or therapeutic innovation is evaluated prior to its introduction into everyday practice. Unfortunately, RCTs have not achieved general practice until recently. Instead, hundreds or thousands of medical activities are currently in everyday practice without ever having been evaluated. Added to the problem of lack of yield is the potential for any medical activity to create adverse side effects, creating harm to the patient.

Why have physicians not performed RCTs? Why has EBM not been the standard of practice? Aren’t physicians smart enough to realize that valid studies are required to demonstrate that a newly introduced procedure deserves appropriate evaluation before being introduced into everyday practice? Indeed, physicians are smart enough. However, they may be too smart, convincing themselves that they are sufficiently knowledgeable to accept a new procedure because it “makes sense.” They also are gullible enough to believe that their mentors in their training years must have already evaluated the procedure sufficient to demonstrate safety and value. Or, as I have often heard from my medical peers, physicians depend on their personal experience in their practices to decide that a procedure is of value, not requiring additional study. Unfortunately, as we learn too late, what is often described as “experience” may simply be repetition of error. All of the above are supported by anecdotes and testimonials, none of which is of any statistical relevance.

Why isn’t EBM more utilized in medical practice? The appropriate studies to prove or disprove a proposed diagnostic or therapeutic activity are expensive and hard work. The average practitioner cannot be expected to have the time, energy, resources and statistical know-how to perform such demanding scientific research. These efforts are left to academic centers, government health entities, and hopefully to a lesser extent, entrepreneurial companies. Further, even when the appropriate studies are performed by capable investigators, they may not be done well. Researchers are human and desire positive results; negative studies are unpopular. In fact, some medical studies are never reported. Drug companies are unhappy with negative results from studies on a newly and expensively introduced pharmaceutical agent and either bury the study or do not encourage further investigation. Finally, the action orientation of Americans, as I have described earlier, both in lay people and physicians, does not manifest the patience required to perform validating studies. Evidence-based medicine is both cost-saving and leads to better patient care. We cannot afford to bypass this critical aspect of medical practice.

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