Beyond Evidence-Based Medicine

          “EBM placed new emphasis on the relationship between clinical research and clinicians’ practice patterns but shifted medicine’s ‘center of gravity’ away from the space between clinician and patient to somewhere between research and clinician. Real progress has been made, but something has been lost, and we believe it must be recovered.”[1]
 
                Having been around a long time, I remember when the researchers at the medical schools routinely bemoaned the resistance of practitioners to incorporate “the evidence” into their practices, but now the academicians are beginning to recognize the practitioners were not quite as irrational as they presumed—they just saw different issues. The editorialists note “intuition-based medicine wasn’t wrong—it was just limited to the data to which physicians had access.” They then go on to point out that if we want to make “interpersonal medicine” part of medical practice, it must be taught. They also note that trust is a foundation of the clinician-patient relationship, so we must find a way to measure it if it is to be promoted. Are they dealing with a “straw-man?”
                I don’t think so. One problem is that “guidelines” with associated clinical performance measures are the way EBM has been put into operation. Tinetti and associates have done a follow-up to an article they first did 15 years ago called “Caring for Patients With Multiple Chronic Conditions.”[2]
 
“We concluded that ‘The proliferation of multidrug regimens demands that we consider health priorities as well as the marginal benefit and harm associated with all medications when translating disease guidelines into prescribing decisions.”
 
                The authors see some progress. Some guidelines now acknowledge the uncertainty of benefit and the importance of avoiding harms. However, guidelines
 
“continue to largely exist in silos that focus on individual diseases…Incentives continue to support aligning medication decision making with disease-focused guidelines rather than patient priorities…”
 
They suggest physicians should return to patient-centered decision-making, saying “we care for patients, not diseases.” While I agree with the sentiment, I find it naïve to think it will succeed when all the incentives are in the other direction. Furthermore, there is increasing evidence that the perverse incentives driving clinical care today are demoralizing physicians, not motivating them to stand up for an unpaid ideal.
 
“The increasingly sharp focus in the United States on the business contours of medicine and the related use of a productivity lens for basing salaries on Medicare relative value units (RVUs) have left many health care providers disheartened…Many of us sense the erosion of time for reflection, for inhabiting that uplifting, quiet place where we know who we are, where we are going, and what we hold to be true…Yet the institutional goals of abbreviating hospital stays and accelerating clinic visits are not the only factors feeding professional loneliness. Meaningful advances in technology have also levied a significant toll in the form of separation from patients and colleagues.”[3]
               
“It seems high time to challenge the assumption that increasing the rate of patient encounters and thereby increasing income is always beneficial for hospitals, practices, and individual practitioners.”
 
                I have certainly seen the quality of practice in my local area deteriorate as cost-containment efforts have pushed the organizational powers that be to push for more “productivity.” A friend of mine says “all systems are perfectly designed to get the results they produce.” Obviously, then, we have worked to build a system which emphasizes cash flow over all other possible values. But is that a system we want to care for us? I don’t think so.
                If we take a step back, I think we can detect a common error underlying all the issues cited by these articles. We want to find “the one best way” to treat diseases and patients, but we know this is not possible. We have different kinds of evidence, different kinds of issues, and multiple points of view regarding desired outcomes. Scientific training emphasizes reduction of variables, “controlling them,” to the absolute minimum. But what we have in medical practice are nested matrices of influences and perspectives. We might be better off if we used chaos theory to model outcomes from manipulations, but in the end, we must also recognize that patients, payers, and providers don’t mean the same thing by “medical care” and don’t want the same things.
                I have argued elsewhere that resilient health care systems are those that can maintain a dynamic equilibrium where the forces from all three perspectives are balanced. This seems clear at the level of the clinical microsystem. Perhaps, then, the common thread in these articles is that dynamic equilibrium needs to obtain at the macro level also. Presently the system is out of balance—money dominates all other concerns. I don’t think that problem will go away, I but do think we need to find ways to balance it with the sometimes competing objectives of patients and providers.
 
12 February 2019


[1] Chang S, Lee TH. Beyond Evidence-Based Medicine. N Engl J Med 2018;379(21):1983-1985. doi. 10.1056/NEJMp1806984.

[2] Tinetti ME, Green AR, Ouelllet J, Rich MW, Boyd C. Caring for Patients With Multiple Chronic Conditions. Ann Intern Med 2019;170(5 February):199-200. doi:10:7326/M18-3269.

[3] Wenzel RP. RVU Medicine, Technology, and Physician Loneliness. N Engl J Med 2019;380(4):305-307. doi: 10.1056/NEJMp1810688.

Further Reading

Knowledge Management
Making the way we do things around here better requires active management.

Medical Evidence, Physician Behavior and The Value Proposition in Health Care
There are different types of evidence which are applicable in different circumstances. In medicine, one size does not fit all.

The Limits of the Medical Model
The tendency to medicalize our problems is not really healthy.

The One Best Way
Medical "Taylorism" persists even though we know it is bad medicine.

Variation in Healthcare: Good, Bad or Inevitable?
A lot of effort is being devoted to eliminating variation, but this is an effort doomed to failure.