Twila Brase, the president of the Citizens' Council on Health Care in Minnesota, has issued a powerful review of the Evidence-Based Medicine (EBM) movement. Her paper, "How Technocrats are Taking Over the Practice of Medicine - A Wake-up Call to the American People," is a landmark analysis of the attempt to bureaucratize medical practice, which has been happening largely under the radar screen of most Americans. In 25 pages, with 226 footnotes, she explains how the underlying assumptions and practical applications of EBM will turn physicians into pawns of the payers at the expense of their patients. EBM assumes, for instance, that variation in medical procedures is inherently bad and should be rooted out so that all physicians do the exact same thing. It ignores that variation in patients may require variation in practice. It assumes that there is one best way to do medicine - and that we know what that one best way is. It ignores that medical knowledge is exploding and what seemed to be right last week may be wrong next week.
One of the most powerful arguments in the paper discusses the validity of practice guidelines, and notes, "In 2000, a group of researchers determined that more than 75 percent of the guidelines developed between 1990 and 1996 needed updating." Ms. Brase says that "they discovered that half of the guidelines were outdated in 5.8 years." Yet the development of guidelines is slow, cumbersome and expensive, taking as long as two years and costing as much as $100,000 - unless the government does it, in which case it costs $800,000.
The guidelines themselves are based on "research" that may be biased, incomplete or self-interested. Certainly we have seen numerous examples of research not getting published because it contradicts the claims of the sponsors of the research. Even the decision of what research to fund is often made for political, not medical, reasons.
Research is often contradictory. Hormone Replacement Therapy was found to lower the risk of heart disease in the Nurses Health Study, while the Women's Health Initiative study found that it increased heart attacks by 40%. But neither study can tell a clinician how to treat one particular woman with one particular genetic profile and one particular set of risk factors and co-morbidities. Population-wide information may be interesting, but it is no substitute for individual diagnosis and treatment. Relying on averages never works when dealing with individuals. In fact that may be the biggest problem with EBM - it is trying to standardize medicine at the very time when we should be customizing medicine so that each patient gets precisely the treatment that is best for his or her particular needs.
Still, research and guidelines for all their flaws can be very valuable in growing the knowledge base. The danger is not the research, but how the bureaucrats want to use the research. They want to control physicians who comply and punish those who do not through the use of financial incentives, malpractice exemptions, and even hospital privileges and licensure, all tied to compliance with EBM guidelines.
This is the polar opposite of consumer empowerment and choice. EBM advocates want only to empower themselves, and we all owe Twila Brase a hearty congratulations for bringing this to the attention of the American people.
SOURCE: http://www.cchconline.org/pdfreport/
Posted by gruwell at December 17, 2004 10:41 AM | TrackBack