Evidence Based Medicine and Reform

This week has been very disappointing, with the USPSTF breast cancer screening guidelines coming out and recieving such an intemperate analysis by virtually everyone with access to a microphone or a camera.

Here is a very thoughtful analysis for those who are interested, but I'm really writing this because of what it says about us as Americans and our love-hate relationship with science.

So, researchers at USPSTF have made an evaluation and recommendations that fly in the face of "common sense." Common sense in America being that more is always better, whether it be testing or surgery or whatever. You can't be overtested, there are no downsides to excessive intervention. Except when there are. I will not go into the downsides of overtesting and overdiagnosing, but it really bothers me that we look to science to advance medicine, to make breakthroughs, to guide treatment and yet, we get a recommendation that falls outside of what we "know" to be true, we flip our collective gaskets.

Apparently, sensing opportunity, Glen Beck had on Bernadine Healy, whom I remember becasue she was in a position of responsibilityin Medicine (she was the Director of NIH from 1991-93), and she apparently doesn't care much for scientific thinking. She trotted out the old saw about prostate cancer survival being better here in America than in the UK because, obviously, the British hate their citizenry.

I have this debunking on the blog here, and it is basically that screening finds things that don't need treatment, but treating all of these cases as if they are life threatening makes our numbers look good. For a better estimate of how the US really does in saving people for dying from preventable causes, go here to see we have the distinction of being 19th out of 19.

But hearing about Ms. Healy being on glen beck reminded me that I had a letter published in US News (that's what the editor told me, though I never actually could find the link - ah, well), after she wrote an article praising anecdote above evidence based medicine. HCRenewal has an analysis here, and here is my letter:

To the Editor:

Healy castigates the practice of evidence based medicine in her polemic as if it were anathema to medical science, and, more particularly, to the individual physician's practice of medicine. Hippocrates knew that "Experience is delusory." "Experience," or anecdote, is sometimes helpful in medicine, but often harmful, because we physicians often internalize our experience into hard rules about treating patients. This often leads us down dangerous paths.

Evidence based medicine is long overdue counterweight to this kind of medical practice. EBM, when evidence is available, makes us think hard about our practices: Are we doing this because that's the way we've always done it, or because we have scientific research to back up our decisions? Sadly, it is too often the former, because the evidence is just not there or has not yet been synthesized into a useful form, or, most commonly, not yet reached the physicians "in the trenches." EBM is not discarding or devaluing physician judgment," as Healy argues, it is rather an attempt to make our judgment more rational.

I find it astonishing that Healy trumpets the jury awarding damages against a physician who did not order a PSA test based upon the best evidence available to him. Every physician should howl in protest at this outcome. Using this standard, we should all have monthly full body high speed CT scans and massive blood testing to search for every possible disorder that comes to the mind of the physician or the patient. But we do not practice this way because it is, yes, I'll say it, stupid!

Evidence based medicine is not a "straightjacket", but a means to an end: providing the best care based on the best scientific evidence we have.

So are we a scientifically based medical community and society, or are we thinking irrationally and letting fear mongers lead us over a cliff?

Don't answer that.

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