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The Goal: Smarter Medicine

By Dr. Chris Lillis
. 3 Comment(s)

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.     

 

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  1. Steve Watkins

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    Breath of fresh air, especially coming from a physician--to subject standard, inherited medical protocols to critical examination to determine genuine effectiveness. Thanks.
  2. Tim McHugh

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    Excellent counter argument to the prevailing procedure and diagnostic test orientation of American medicine. We are innovators in terms of technology, but we have fallen behind in our ability to listen to and care for the individual. Thanks for this blog!
  3. Charles Bagley MD

    Permalink
    Unnecessary testing, procedures, surgeries etc. are generated by the fee schedule which is determined by some committee at the AMA. These unnecessary expenses are routine in American medicine and a violation of the "Do no harm" pledge of the medical profession. Europeans have a different fee schedule and pay 1/2 of our costs for results that are about the same or better. The fee schedule is biased toward those tests, procedures, etc.. The fee schedule is an extension of what I call "proprietary" medicine: if it is not a patentable drug or a procedure that requires years of specialty training (and thereby confers a proprietary status to that specialty) it will not become part of the conventional treatment paradigms. Nonproprietary medicine
    (sometimes referred to as "alternative" medicine)has arisen as a choice but often (foolishly) not recognized by insurance. I have proposed the following health care reform to correct this situation: create an HMO in which primary care doctors properly trained in the best alternative medical techniques would be given a panel of 2000 patients. If each patient pays $500/month in health care premiums, the doctors panel will receive $1 million/month; all of the expenses of those patients are paid out of this account. If the doctor is successful in keeping patients healthy and solving problems in the primary care setting (thereby keeping the expensive specialists out of the loop), money will accumulate in the account and can be distributed to the doctor as a bonus when actuarial analysis determines that a statistically valid excess has occurred. Combined with other assessments of the health of the panel, the excess will be a scientifically valid measure of the overall performance of the doctor. Anyone interested in promoting this idea please contact me. Charles Bagley, M.D. cbagleymd@aol.com

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