More on "Evidence Based Medicine" and "Sex-based intercourse"

Sincere thanks for all the comments, and the healthy debate. Democracy and civil discourse at work!

To respond to a few points from "A Concerned Physician" :

Of course, I am all for preventive medicine! Drugs for hypertension to prevent stroke, Vit A for blindness. . . who could be against that.? But if you put forth the hypothesis that preventive care will SAVE money (as the President proposes) . . . well, I'm sorry to tell you that the evidence (yes, evidence!) isn't there. The fact is if we do the right thing, cover everyone, get everybody to have regular check-ups, you will prolong life and uncover lots of treatable conditions that need investigaton, consultations and more treatment. I'm all  for that. But it wont save money.

So please do read the article by Marmor et al titled, "The Obama Administartion's Options for Health Care Cost Control: Hope vs Reality"  in the Annals of Internal Medicine (which I hope you will agree is ).  The Congressinal Budget Office's reports  projects little savings in this fashion.

As for IT and Electronic Medical Record (EMR), I'm no Luddite. I use it and can't remember what life was like before EMR. But again, if the thesis is that computerized records will SAVE money . . . well, I'm sorry but the evidence does not back that up. The  Congressional Budget Office estimates that EMR will reduce national health care spending only "by an estimated $8 billion over the 2010-2019 period (or by less than one tenth of 1%)".  In other words we are proposing to spend 20  plus billion to achieve these savings. [See the 08 Congressional Budget Office report, "Evidence on the Costs and Benefits of Health Information Technology "- -our taxes at work to produce these studies for us to read and hopefully save goverment from wasting tax money.]

The other problem which is more subjective and qualitative, is the effect the computer has on distancing physicians from the patient.  I visited an ER with a friend recently, and nurses, docs, lab techs were interrogating the patient over their shoulder while making entries in the computer! It went on for hours. It was subjectively a poor experience overall for the patient, but if you were to study her record, I've no doubt it would shine and glisten like a jewel!  The iPatient got wonderful care, while the real patient left disillusioned with medicine.  I do think the EMR impedes medical education. (the link is to an article in PLoS) .

Finally, I don't think we we disagree on what we'd like for our patients, or on the benefits (from the time of Edward Jenner and small pox vaccine) of good science to find the best ways to treat and diagnose patients.  But what I find annoying is the slavishness to that non-sequitir, "Evidence Based Medicine" that seems to shortcut critical thinking: I've seen too many patients railroaded into the "critical pathway" for pneumonia based on the best of evidence-based medicine, and by every metric the physicians did well and the hospital is pleased. The only problem was the patient didn't have pneumonia, but heart failure! A little more face time and less haste to plug people into EBM algorithms as if we are herding sheep down chutes would do much for patient satisfaction and improve medical care. We simply have no idea of the costs of those kinds of medical errors, of wrong diagnoses from people not spending time examining and interrogating the patient and re-examining and re-interrogating the patient.

So, to "Concerned Physician: I'm equally concerned. Alas, contolling costs, as our parents taught us, is best done by cutting costs, not by pie in the sky schemes that are postulated to save money. The remedy is painful but necessary.

p.s. I happily accept your label that my conclusions are drawn from ignorance. At least you and I will have the joy of not being alone! (-:

 

 

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Abraham Verghese is an author, physician and med school professor. He is the author of Cutting for Stone and his writing has appeared in many major publications. More

Abraham Verghese is a physician and writer. His third book and first novel, Cutting for Stone, was published by Knopf in 2009. He is also known for two acclaimed non-fiction works, My Own Country, which was based on his experiences working with persons living with HIV in Johnson City, Tennessee; that book was a finalist for the National Book Critics Circle award and was made into a movie. He followed that with The Tennis Partner, also a New York Times notable book and a national bestseller. His writing has appeared in The Atlantic, The New Yorker, The New York Times , The New York Times Magazine, Sports Illustrated, and The Wall Street Journal as well as many medical journals. Verghese is board-certified in internal medicine, pulmonary medicine and infectious diseases. He attended the Iowa Writers Workshop at the University of Iowa where he earned his MFA. He currently practices and teaches at Stanford University School of Medicine where he is a tenured Professor and Senior Associate Chair for the Theory and Practice of Medicine in the Department of Internal Medicine.

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