It’s been a chatterbox kind-of-week for evidence-based medicine.
First, an article appeared in the New England Journal discussing its limitations. Then, a rebuttal came from an established bull in the China shop, and we were well on our way. Ultimately, all sides made a point.
Seemingly bored by the chatter, however, may have been Medical Progress herself. She has and will continue to move forward on her own terms—sometimes with and sometimes without randomized controlled trials.
There are not many novel ideas to discuss here. Evidence frequently has claimed to be guiding medicine. Sometimes it has originated from the experience of a single person or two. Sometimes pseudo-clarity has required the trials of ten-thousand. Only very recently has evidence even existed for some in hierarchical structure—”hard” or “soft” these people now say.
But, what does “hard” or “soft” evidence really mean anyway? And, who gets to define these terms?
The policy makers?
The New England Journal?
The bull? The baker? The candlestick maker?
Almost contrary to what the gnostics of evidence proclaim to be best, the majority of individual medical decisions are made using so-called “soft” evidence. And, no, this isn’t some atrocity.
I arrived with my family. I handed the usher our tickets.
We entered the auditorium. The stage was lit. We were directed to our seats.
We were there to watch an OPAS Junior production—a performing arts play for families and children.
The performance would soon be what we paid for, an enjoyable Sunday afternoon event with my wife and boys.
The actors and actresses did their job. They appealed to us, the audience. They danced, sung songs, provided humor, and so forth. They were there for us that day. And, we were there for them.
We paid for their performance. And, they gave us one.
* * *
A compelling strategy has consumed American healthcare. It’s known as pay-for-performance. It’s trying to replace our unknown fee-for-service model, because it seems more logical.
I enjoy documentaries. My wife says she enjoys watching them with me. The way I usually see it, they help her fall asleep.
But, not this one.
Not Poverty, Inc.
If you haven’t watched it, you should. We both enjoyed it.
It’s not one of these pick-a-political-side kind of shows. For the record, people across the political spectrum have endorsed it. The film has won like forty honors and twelve awards that I know absolutely nothing about. But, if you watch it, you’ll get the gist why.
We occasionally need disruptive thinking. Something to challenge our perception of reality. We actually need more of this when contemplating healthcare delivery, too. But, I’m not talking about that right now.
Poverty, Inc. is about poverty… and the humanitarian aid we use to fight it.
It’s also about government. And, business. And, how the collusion of these things isn’t solving poverty at all. Like I said, you should watch it. It provides you a fascinating perspective.
I won’t give it all away, but there are a few predominant themes that unfold in the film as you watch it.
American tax payers have spent billions funding our current healthcare computer systems.
“Cash for Clunkers,” he calls it.
“[The legislation] gave $30 billion,” says technology entrepreneur Jonathan Bush, “to buy the very pre-internet systems that all of the doctors and hospitals had already looked at and rejected.”
And, he’s right. We’re using clunkers. Paid for by the U.S.A.
The reason for this is simple. These government subsidized and heavily regulated software systems were never designed for the physician end-user. They were built to satisfy thousands and thousands of pages of federal regulations. And, they’ve essentially achieved two things: (1) to create privilege for some, and (2) to politicize everything for the rest of us.
In this post, I examine the firestorm surrounding Dr. Lisa Rosenbaum’s article, N-of-1 Policymaking — Tragedy, Trade-offs, and the Demise of Morcellation, which was published in the New England Journal of Medicine in March 2016. To appease the medical pious everywhere, I disclose that I have never met Dr. Rosenbaum in person. I do follow her on twitter @LisaRosenbaum17. I have no financial stake in power morcellation, a medical procedure that I will discuss below. And, yes, I dislike bullies.
Mostly normal people leading normal lives don’t speak out very much.
They just sit there. They read stuff. They watch news stories.
They may very well be engaged with a topic. But, they will infrequently write reviews or give comments. That kind of stuff usually always comes from the extremes. And, as you know, the extremists either love you or they hate you.
Dr. Lisa Rosenbaum got the extremists juiced up earlier this month by writing an article about the tradeoffs and demise of a medical procedure known as power morcellation. If you’re a normal person that happens to run in my professional circle and have been following this saga, I suspect that you have moved on. That’s what normal people do with non-stories.
If, however, you are an extremist, you continue to write about it. That’s me.
I wrote previously about the ongoing federal approval process for a medical device known as the WATCHMAN™, now available to treat certain patients at risk of stroke.
As expected (and really just because it’s how things get done around here) the Centers for Medicare and Medicaid Services (CMS) has compiled a 32,000 word decision memo related to how it intends to pay (if at all) for patients receiving this approved device. This memo is commonly referred to as a coverage determination.
A thoughtful piece was also written recently by Dr. John Mandrola on this very topic. He and I usually share many of the same goals, although admittedly, we differ from time to time on how best to obtain them.
Regardless, Dr. Mandrola’s piece is full of clarity and is very supportive of CMS’s intent to require an evidence-based formal “decision tool” to be used by the physician and the patient prior to implanting the WATCHMAN™.
Sometimes perspective is helpful.
Even when given just a little bit of it.
Presidential candidate, Sen. Bernie Sanders, has recently released his “Medicare-for-All” plan. Similar to his make college education free plan, there are a number of things admirable about it. No healthcare deductibles. No co-pays. No fighting with insurance companies. We all get, seemingly for “free,” whatever the government thinks we need.
And, I get it. In 4th-grade, I once ran for student council touting a “No Homework For All!“ slogan. I’m not even saying this is the same strategy being used by Sen. Sanders. Instead, I’m just trying to imagine the ideal:
A world where all of us have (1) the healthcare we need, (2) when we need it, (3) at the most reasonable cost to all of us, collectively.
There is a single CT scanner in town.
A certain number of scans are done with it each month.
Suddenly, a second scanner is installed at a new location across town.
True or False:
The total number of CT scans being performed will remain the same with two scanners now available.
The answer is false… at least within our current system. Someone has studied it. Adding another scanner increases the utilization of scanning.
Is this a good thing or a bad thing? Careful, now. It’s an entirely different question. The answer, of course, is maybe, or maybe not. You need more information.
My wife and I had planned a three day trip to celebrate our anniversary.
Extended family was in town to watch our boys over the long weekend while we were going to be away. And, yes, it’s always challenging getting out the door.
I’m not talking about the often bizarre scenarios that befall my private-practice patients in the hours leading up to any scheduled vacation. I’m really just talking about parenting.
If you’ve been there… you know. You just know.
The school lunch supplies must be lined out and ready to go. Clothes have to be washed. Instructions for this and that must be given for the extended family. I really thought I stressed about these things far less than other parents, until I saw my kitchen completely covered with post’em notes.