Don’t let the headline fool you: I am not against evidence based medicine when it is used as a guide for doctors to provide optimal individualized care. But I am against using EBM as a method of establishing categories for health care rationing–whether of “what” or “who”–as I believe we are destined for under Obamacare. One reason is that–like global warming computer models–it all depends on what evidence is included or excluded in creating the studies. That means the evidence could well be cooked.
This point was acknowledge in the New York Times, of all places, in a recent article on end of life care. From the story:
The Ronald Reagan U.C.L.A. Medical Center, one of the nation’s most highly regarded academic hospitals, has earned a reputation as a place where doctors will go to virtually any length and expense to try to save a patient’s life. “If you come into this hospital, we’re not going to let you die,” said Dr. David T. Feinberg, the hospital system’s chief executive. Yet that ethos has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.
Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not. That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.
Perhaps not so remarkable. I don’t know if it is true in this case, but the scientific study has become a method of ideological advocacy, and in such reports, the deck gets stacked. In other words, sometimes the authors of such studies know what they don’t want to know because they have a result in mind rather than dispassionate analysis.
The Times gives an example:
Take the case of Salah Putrus, who at age 71 had a long history of heart failure. After repeated visits to his local hospital near Burbank, Calif., Mr. Putrus was referred to U.C.L.A. this year to be evaluated for a heart transplant. Some other medical centers might have considered Mr. Putrus too old for the surgery. But U.C.L.A.’s attitude was “let’s see what we can do for him,” said his physician there, Dr. Tamara Horwich. Indeed, Mr. Putrus recalled, Dr. Horwich and her colleagues “did every test.” They changed his medicines to reduce the amount of water he was retaining. They even removed some teeth that could be a potential source of infection. His condition improved so much that more than six months later, Mr. Putrus has remained out of the hospital and is no longer considered in active need of a transplant. Because Dartmouth’s analysis focuses solely on patients who have died, a case like Mr. Putrus’s would not show up in its data. That is why critics say Dartmouth’s approach takes an overly pessimistic view of medicine: if you consider only the patients who die, there is really no way to know whether it makes sense to spend more on one case than another.
And here’s where Obamacare comes in:
Under the House health care legislation pending in Congress, the Institute of Medicine would conduct a study of the regional variations in Medicare spending to try to determine how to reward hospitals like Mayo for providing more cost-effective care. Hospitals identified as high-cost centers might even be penalized, perhaps receiving lower payments from the government…That prospect worries Dr. Rosenthal and his U.C.L.A. colleagues, who say that unless the distinction can be clearly drawn between excellence and excess in medical care, efforts to cut wasteful spending could be little more than blunt rationing. “There’s a real risk of doing harm here — real harm,” he said.
This is a very good article, illustrating that the outcome of “studies” depends on its design, and indeed, they may mislead more than they edify. That point aside, this is a prime example of why it would be wrong to begin treating patients as members of a category instead of as an individual. Statistics provide general guidance. But they are no substitute for personalized care.
December 23rd, 2009 | 12:52 pm
[...] This post was mentioned on Twitter by Vince Humphreys, Wesley J. Smith. Wesley J. Smith said: Obamacare: The Danger of “Evidence” Based Medicine » Secondhand Smoke | A First Things Blog – http://shar.es/aOdEJ [...]
December 23rd, 2009 | 1:39 pm
By any other name this could be looked at as death panels:
“Under the House health care legislation pending in Congress, the Institute of Medicine would conduct a study of the regional variations in Medicare spending to try to determine how to reward hospitals like Mayo for providing more cost-effective care. Hospitals identified as high-cost centers might even be penalized, perhaps receiving lower payments from the government…”
December 23rd, 2009 | 5:08 pm
“the evidence could well be cooked.”
Canada just set up an “expert” panel to bend information in support of euthanasia.
http://www.lifesitenews.com/ldn/2009/dec/09122109.html
December 23rd, 2009 | 8:28 pm
Critisizing individual studies is great, but don’t come out and say that science itself, or the use of evidence to make decisions, is bad. What’s our alternative? Just guess what to do? Pray for the answer? If you don’t like how one study was run, you should suggest an idea for another better one, not just say that science is evil.
Also, this article ignores a huge factor in this issue: We are trying to find the balance between encouraging the running of needless tests JUST TO MAKE MONEY, and yet still doing everything to give the patient every possible chance. It’s not fair to say that Obama is evil just because he supports a policy that rewards reducing waste, which can be slanted to inaccurately imply that we should use fewer tests even when they might be helpful. The whole point is to determine exactly when they might be needed, not just reduce medical care in general. Yes, we will need evidence to figure that out…
I haven’t seen a single thing to suggest that current healthcare reform will reduce personalized care.
December 23rd, 2009 | 11:48 pm
This highlights a very interesting aspect of the discussion that investment folks understand b/c of the exact issue – and interestingly, in investing, its called ‘the survivor bias’. Long-term mutual fund performance only evaluates those funds in a particular asset class (in medicine, a category) that are still in business, that have survived, to this point. The loser funds are just gone. I would suspect that with lives at stake and the data readily trackable in medicine, that having information on the survivor bias would be an obvious inclusion in studies. But I suppose common-sense and ethics is asking too much when intellectual dishonesty is so much more prised.
December 24th, 2009 | 7:52 am
As one of my epidemiologist friends puts it, if your doctor tells you he practices “evidence based medicine” get out of the examining room as fast as you can!
December 24th, 2009 | 8:24 am
Yes, medical care is more expensive than it used to be.
In 1959, a 55-year-old business executive stricken at his desk with crushing chest pain did not call “911″ — it didn’t exist. EMTs and Paramedics did not respond — they did not exist. They did not perform CPR — it hadn’t been invented. They didn’t apply “paddles” to defibrillate his writhing cardiac muscle — it hadn’t been invented. There was no CCU to take him to. There was no lidocaine drip and no monitor to watch. There were no echocardiograms, no MUGA-scan, no perfusion scan, no cardiac catheterization, no clot-busting drugs, no ballon angioplasty, no stents, no coronary-artery-bypass-grafts, no decent anti-arrhythmic drugs, no cholesterol-lowering drugs, not even any decent blood pressure drugs.
What there was, was a gentle, wise, compassionate, white-haired cardiologist who was so effective in consoling his widow and children.
Which didn’t cost very much, either.
Today, with all of that high-tech medical care in place, the businessman goes home, alive, after a week or so in the hospital, and he is back at his desk, working a full schedule, within a month.
Of course, it cost $250,000 or so.
And if it was God’s will that the patient didn’t survive, why you’ve just spent $250,000 in the last six months of life! In the last week of life, actually.
So who’s going to decide when your last week has arrived? God? or a Federal bureaucrat!
Merry Christmas to all who celebrate the day!
December 24th, 2009 | 10:51 am
Punditarian,
The businessman in your example paid for his $250K worth of coronary care himself, either directly, or by purchasing insurance, or by some combination of the two. The fundamental problem is that the mojado who cuts your lawn expects to receive that same $250K worth of care for his coronary at someone else’s expense, and politicians seem inclined to accommodate him. My preference would be to remove both God and the federal bureaucracy from the decision process, and leave it to the free market.
Bah! Humbug!
December 24th, 2009 | 12:24 pm
>>We are trying to find the balance between encouraging the running of needless tests JUST TO MAKE MONEY>>
Not necessarily to make money – absolutely in order to avoid lawsuits.
December 24th, 2009 | 1:56 pm
I don’t see the problem.
If you don’t support your tax dollars being spent for my reproductive services, I don’t support my tax dollars paying for your brand-name drugs and overpriced, futile treatments.
I thought you were all about “free-market” anyway. You want something extra, pay for it.
If it should work so well for women, the poor, minorities, elders and gays, it should certainly work as well for “gratuitous” treatment of patients.
Touche.
And all this continued rationing talk is silly. With 50 million Americans without health care, 45,000 dying every year from lack of coverage, we already ration by class.
All I hear in this argument is those with great plans – and particularly those in the fat medical industry – complaining that they have to give up their futile treatments brand-named money-makers so the underprivileged can have access.
Sounds like self-righteousness to me.
December 24th, 2009 | 5:31 pm
Thank you, Gringo Malo, for noticing my comments. I don’t have a mojado to cut my lawn, but I would bet you a chocolate milkshake that almost anywhere in the United States today an indigent middle-aged man with no insurance wandering into an Emergency Room with substernal chest pain and ST-T wave elevations would get all of the care described above — without ObamaCare. The hospital and the doctors would “write it off” but it would result in higher overhead and higher prices for everyone else.
All of our notions regarding ethical behavior on the part of the institutions that provide medical care services are the product of an earlier era, when what few medical services existed could be provided at practically no cost. The fact that we now have medical treatments that work is the biggest difference.
By the way, I think that the notion that 45,000 people die every year because they have no health insurance is rhetorical legerdemain. The idea that 50 million Americans have no access to medical care is also false. And the belief that the FDA would be willing to register an ineffective, futile drug is just foolish.
December 24th, 2009 | 11:10 pm
Ann-I’m sorry, but that is “sick” thinking. You are equating access to birth control pills with access to life saving care. the fact that you equate society’s responsibility to a patient’s life with it’s responsibility to your reproductive choices is truly frightening.
December 25th, 2009 | 10:26 pm
When the Ameicans of the older generation went to school they were taught about the Constitutuion and the Declaration of Independence. They also fought a war against Fascists and a Cold War against Communists to stop the spread of ideologies and dictators that would threaten those documents and their principles, and spread freedom around the globe to other humans. That and “cost savings” which the people writing these bills don’t seem to care about anywhere else seem to combine to make them worrisome to the idiots in DC these days writing thi absolute garbage and lining their own pockets and their buddies’ pockets.
Wesley J. Smith Reply:
December 25th, 2009 at 11:01 pm
I guess it’s a matter of, “What have you done for us lately?”
December 27th, 2009 | 10:28 am
Gee, Jersey Dave, when I learned about the Constitution there was a phrase in the Preamble that said something about promoting the general welfare. Remember that? So who’s making war on our national principles these days, may I ask?
December 27th, 2009 | 11:44 pm
HW:
The preamble to the Constitution has no legal force. It’s an introduction, for crying out loud. The government could do near anything and justify it under “providing for the general welfare”. Power given to the government comes in the articles and amendments, and is precisely defined. The preamble’s bit about “provide for the common defense” enables the government to do nothing. Those powers come later, in articles I and II. One of our founding principles was, and I hope still is, LIMITED GOVERNMENT.
December 28th, 2009 | 7:39 am
SparkVarc: Jersey Dave mentioned “those documents AND THEIR PRINCIPLES.” I agree with him that we have fought wars to defend the principles expressed in them.
You, on the other hand, seem to be saying that only the bodies of the documents have any relevance, not any statement of their principles. You seem to forget that the phrases such as “endowed by their Creator with certain unalienable rights,” and “life, liberty and the pursuit of happiness” incorporated in the Declaration of Independence have no legal force either, but we DO base our form of government on those principles. Think the language is irrelevant? Ask any pro-lifer.
The writers of the Constitution obviously believed that one of its purposes was to promote the general welfare (“in order to ….do ordain and establish this Constitution”), otherwise it’s unlikely that they’d have included that language in its preamble.
We may differ as to precisely what might be included under that heading, but we can’t doubt the writers’ stated intentions. The document says what it says, and intention has always been one of the criteria of legal interpretation. Do you think you might have expressed their ideas more clearly…?
December 31st, 2009 | 11:19 pm
Jim: I don’t think Wesley is criticizing science; because, by definition, when bias enters, a study is no longer scientific. Am I right?
Ann: Who said anything about tax dollars? I’ll own my debt. All I ask in return is not to be bullied by the government into purchasing insurance I don’t need or want.
HW: this is an interesting time for you to adopt a pro-lifer’s argument.
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