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Comparative Effectiveness Research: Follow the Herd or Lead It?

Posted Apr 25 2010 8:41am
I never took a psychology course in my life. Perhaps, I should have. How was I to know, or even suspect, that years beyond college, I would be the father of 5 kids? In retrospect, I should have been a psych major, so that I could have developed essential parenting skills in negotiating techniques, behavior modification, unflappable self control, brinkmanship, verbal dueling and mind reading. Without a solid psychological foundation, I have been fenced in and cornered by teenagers who know very well that I am shooting blanks. This has not been a fair fight.

Two weeks ago, my daughter and I traveled to the east coast to visit 3 institutions of higher learning. This is the 3rd child that I have done college visits with. By now, I could give these ‘info sessions’ myself. They are verbal versions of Mad Libs, where the speaker simply plugs in terms specific to his institution. For example
“What really makes __________ University so unique, is our (insert superlative adjective) professors. In our institution, (select a number between 96-99) % of all courses are taught by full professors. They (insert gushing verb with exaggerating potential) undergraduates! Ou professors would much rather hang out in office hours teaching you Physics 101, then pursuing their (insert adjective that is synomym of boring) research with grad students who worship them. For our profs, teaching trumps tenure. An advantage to having a campus in the middle of nowhere, is that our students can (insert activity that sounds amazingly fun even if it doesn’t exist on campus) every weekend.

The sessions often with remarks suggesting that the college can be anything the applicant desires.

"Our institution combines the advantages of a large research university with a small liberal arts intitutions.  It is both urban and rural.  It strives for collaboration and cooperation, but encourages independent inquiry.  It is both vegan and carnivorous..."
You get the idea.

Like most parents, I want our kids to be exposed to a spectrum of ideology. Even without a psych background, I coyly influenced my daughter’s choices so that we would be visiting 3 colleges that were philosophically distinct.

      College                                Campus Philosophy

Standard Ivy League                           Liberal

Urban Liberal Arts University         Really liberal

Small Liberal Arts Institution           Socialist

After the ‘info session’, the high schoolers and their parents tour the grounds. This is when various campus features are pointed out that will surely determine if that particular college is the right choice. Here are some sample comments that demonstrate the value of the campus tour.

“Here is the chemistry building. This is where we study chemistry.”
“This is a dorm room. Can everyone see the sink?”
“Our library has 14 gazillion volumes. Most colleges of this size only have 11.”
“This is our main cafeteria. I just started giving tours, so I don’t remember what happens here.”
At the beginning of one of these tours, I witnessed a real live psychology experiment in progress. The courteous admissions staff had provided us with umbrellas as rain was likely. Minutes later on the tour, it started to drizzle. It wasn’t real rain yet, but was steady enough to be annoying. Although we were getting wet, no one opened their umbrella. My daughter whispered to me, “Can I open it?” I needed to think quickly as the wrong advice could jeopardize her chances of admission. “Go ahead,” I replied. She complied. Within 30 seconds, every other umbrella popped open. All this crowd needed was for one person to act, so they could all follow. Why didn’t they act at the proper time? Even my daughter wanted my approval before taking bold action.

Folks are comfortable when they are following the herd. I wondered about this observation with regard to the medical profession. How many of our medical actions and decisions are done in imitation of others? How many of our practices are examples of group think and playing follow the leader? Why does medical dogma and practice take so long to modify?

Physicians, including me, perpetuate practices that may be more based on custom and tradition than on sound or changing medical evidence. Here are some examples, most from my own specialty.

  • Physicians continue to support Prostate-Specific Antigen (PSA) testing despite mountains of evidence against this practice.
  • Gastroenterologists perform colonoscopies reflexively to evaluate fecal occult blood, even though this exercise only rarely yields a significant lesion.
  • Cardiologists stent narrowed coronary arteries that should never have been discovered and aren’t responsible for clinical symtoms.
  • Gastroenterologists have been obtaining biopsies from patients with Barrett’s esophagus on a regular basis for decades, even though there is no persuasive evidence supporting this practice.
  • Hepatitis C is treated with toxic medications that don’t work well. They are widely prescribed.
  • Remicade and its cousins have become mainstream treatment in inflammatory bowel disease. My review of the data, even with publication bias, shows rather modest long term benefits, despite risks of opportunistic infections and cancer. The medicine cost a fortune and are often given lifelong.
  • Acute pancreatitis had been treated with bowel rest for decades, until recently.
  • Helicobacter pylori is an enemy of mankind and must be eradicated in our lifetime.
  • Sequential rounds of chemotherapy for incurable diseases are often prescribed because this is a mainstream oncological practice.

Medicine is a great profession, and it can be better. We physicians need to be more skeptical and creative. We should challenge our own clinical practices periodically to verify that they are truly best practices for patients. It is not be enough for us to ‘do what we were trained to do’. For a long time, gallbladders and uteruses were yanked out for reasons that would not survive strict scrutiny. I enthusiastically endorse comparative effectiveness research, although I expect it will be provoke fierce battles from those whose economic survival depend upon the results

It’s easy and comfortable to keep on the same path without deviation. We need folks, however, who will shake it up and make us think, explain and justify what we do. I know that my own practice could stand to be shaken up. Patients can be part of the process by asking us pointed questions, such as, “Doctor, explain exactly why I need this test or medication now?”

There is an undertow that pulls all of us to follow the herd. This is perfectly fine, depending upon the herd’s destination. If it’s headed the wrong way, however, it’s not easy to change a herd’s direction, but it can be done. One person has to stand up when it’s raining and lead the rest of us to drier ground.
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