Rationing vs. evidence
Wednesday, September 23 2009
Sharon Begley in Newsweek has a mind-twistingly convoluted argument against… wait – is it rationing? or evidence-based medicine?
What do you want to bet that, whatever happens to health-care reform (since the nation will continue to struggle with skyrocketing medical costs), in the current climate of rationing fears, they will be suspicious, even furious, believing that their child is being denied proper medical care for some nefarious economic reason? Yet the conclusion that children with head injuries do not necessarily need a CT scan—and that such scans expose them to high levels of cancer-causing radiation for no benefit—is supported by the largest study of its kind.
Let me try to unpack what’s going on in this paragraph and the larger article:
- Begley is writing about evidence-based medicine. She is neither for nor against it, as far as I can tell.
- Begley believes that patients and parents won’t understand the reasons they are denied certain treatments.
- Begley believes that given the current hysteria about rationing, parents will assume that their care is being rationed.
- Begley believes that most Americans – especially parents – will refuse to allow their care to be rationed.
Even if a majority of the people who need medical care are as dumb as Begley thinks they are, per #2, how exactly is #4 going to happen? Are angry parents going to shop their injured kids until they find that CT scan? Are patients going to write letters to Congress denouncing their doctors’ judgment?
The fact is, patients are denied treatment and testing all the time – and we’re mostly powerless to do anything about it. I wish there was evidence behind those decisions, but often it has more to do with whims, ignorance, or financial interests. Sometimes, we can’t even get the treatment the evidence says is right for us. Consider this story from Trish Torrey, about a patient suffering side effects from statins. I’ve had similar situations, too – where I knew the proper course of treatment, but was powerless to get my physician to follow it.
Begley is blaming patients for problems with a reform that hasn’t even happened yet. Meanwhile, I don’t know any doctor who thinks effectiveness research – the evidence in “evidence-based medicine” – is a bad idea. How doctors explain that evidence to their patients is maybe an issue, but it’s not the same issue as rationing. Yet Begley is fomenting the hysteria she finds so worrisome; the big, bold headline of her piece is:
Rationing? Not My Kid!
If the “current climate of rationing fears” is an obstacle to medicine based on science, Sharon Begley will be among those to blame.
(via Kevin, MD who argues that “patients need to shoulder some of the blame”)
Thanks for the comments. fyi – Begley has historically been in the corner of evidence and comparative effectiveness research:
http://www.newsweek.com/id/187006
Kevin
Just a quick post but, I’d like a bit of clarification on your post — in particular, I was struck by your quote — “where I knew the proper course of treatment, but was powerless to get my physician to follow it.” — it seems to imply that you have formal medical training, which doesn’t seem to be present in your biography.
Anon – I certainly didn’t intend to imply that I had formal medical training training. Such training is not the only way one can learn useful facts about medicine. It’s a common and understandable mistake to assume otherwise, but in many cases patients with a history of chronic illness end up learning a good deal about their disease, it’s symptoms, and appropriate treatments. In fact, after 15 years of Crohn’s disease, I know as much or more than many people who can claim formal medical training. The challenge for someone like me is getting those sorts of people to recognize the value of the knowledge I bring to the table. Too often, they simply refuse.
Excellent reply, and much appreciated.
I have no doubt that, as you say, there is substantial value to the knowledge of information that a chronic illness patient can bring to the table — in fact, I’d go as far as saying that you know more about your illness than many medical professionals in other fields (say, a psychiatrist specializing in bipolar disease or a infectious disease specialist who researches the Ebola virus). However, I strongly disagree with the proposition that you can possibly know more than your personal primary care physician.
Let’s say that I live in a house which has a chronically broken toilet. I know what sounds it makes before it’s going to quit, I know how to jiggle it in a certain way to convince it to work, perhaps I’ve even watched the plumber fix it. Given my substantial experience with my broken toilet, does this give me as much expertise in the domain of toilet repair as my plumber? I don’t think so.
Anon – the question, as I understand it, is whether or not I could ever know the the proper course of treatment better than my physician. As it happens, I once developed a fistula and told my personal primary care physician it was a fistula. He told me it was not a fistula and that we would be not be treating it as such; because I believed doctors always know best, I let him convince me it was not a fistula. Sometime later, after I saw a second doctor, I learned that it was in fact a fistula and that my primary care physician had always been wrong. The problem was that my PCP had never seen a fistula before; this would be analogous to a plumber who had never seen a broken toilet before. In this case, I did in fact know more about the pathology and treatment of my disease than he did. That is one example; I could list more, but this should suffice.