Earlier this week, Dr Evan Saulino wrote about American Innovation in the context of finding innovative ways to fund health care. Like most Americans, I feel excited and energized by thinking about American exceptionalism, and understand that many good things can happen if we harness innovation to solve our current day problems.
Innovation and America are practically synonyms. Whether its microchips, new pharmaceuticals, or even computers that can beat humans in Jeopardy!™, we can see examples of innovation all around us.
But what about the direct medical care that we physicians provide to patients? I would think Americans would be shocked to know that almost half of the medical care that takes place in our country is not grounded in rigorous science. For years, surgeons performed arthroscopic knee surgeries for knee pain, because that was essential medical dogma. A simple study that was performed comparing arthroscopy to sham surgery was able to demonstrate that patients who received “real” surgery fared no better.
And here is where the argument usually begins. Opponents of comparative effectiveness research and evidenced based medicine will begin to demagogue about “freedom” in healthcare, the sanctity of the patient-physician relationship, or the dreaded “rationing” that will occur if we allow funding of comparative effectiveness research.
Let me help translate: there is a lot of money to be made by continuing to perform useless procedures that, at best, don’t really help patients, and at worst, actually harm patients. I recall a recent encounter with a patient in my office. She had been to dozens of doctors and specialists seeking relief from her abdominal pain. She had functional abdominal pain, and was subjected to countless CT scans, ultrasounds, and MRIs without finding a source of her pain. Despite this, various surgeons through the years had managed to remove her gallbladder, uterus, ovaries and finally a large section of her small bowel. She was never rid of her abdominal pain. All this was done before she ever met me, and when I explained to her the correct diagnosis, and that I was not surprised none of the previous surgeries had helped, she broke down in tears.
An exciting recent example of comparative effectiveness research – that will improve patient outcomes AND reduce medical costs - pertains to our approach to breast cancer. Just like many years ago, when we learned that less radical lumpectomies for limited stage breast cancer were as effective as radical mastectomy, we now know that limited removal of lymph nodes is just as effective as a more extensive surgery. The result? Lower cost. Better care. A happier, healthier patient, without any less success in providing disease free survival. This is the antithesis of rationing; it is the improvement of patient care.
Not all research looking at effectiveness is this narrow. Some studies, like the study undertaken in Camden, New Jersey highlighted by Dr Atul Gawande , show that community based programs for the chronically ill not only improve health outcomes but drastically reduce health care costs.
Comparative effectiveness research challenges current day dogma, and as physicians we must be humble enough to admit if our practice patterns have not previously been effective. Research can help distinguish between effective medical therapies and ineffective ones, and if I remember correctly, I took an oath to first do no harm.