Tuesday, January 5, 2010

Why does Common Sense seem so Uncommon in Health Care?

I was reading Dr. Peter Laird's post on Bill Peckham's blog:  Dialysis from the Sharp End of the Needle. Dr. Laird was lamenting that "evidence based medicine" may be a barrier to optimal dialysis.

"Evidence based medicine" has become one of the latest buzzwords in medicine. It refers to the research back-up for what we do in practice. Specifically, is there adequate research to justify certan screening tests or treatments? Will enough lives be saved to justify the attendant risk and expense? (Hauntingly, this all reminds me of airlines quantifying "acceptable" lives lost in improving safety standards!)

But we all learn in medical school to be critical readers of research studies. Some studies are better designed than others; we should assign more credibility to these. For example, how many people participated in the study? Was there investigator bias? Was a study funded by a source that stood to gain monetarily? Was the conclusion represented in the abstact synchronous with the study's "fine print?"

As clinicians, we live in a real world of elusive and ill-defined factors: clinical experience, that compelling "gut feeling" about a patient, and that all-too-rare common sense!

Last month, for example, we heard new recommendations for mammogram screening--to start in all women at age fifty. Of course, there was a qualifier: high risk women could start earlier. That very week in my practice, we found a forty-nine-year-old women with a multicentric infiltrating ductal carcinoma. She wasn't high-risk by typical standards, but she would have assuredly been missed had we followed this proposed guideline. In my practice, our youngest patient with breast cancer was twenty-nine. Most of my patients get mammograms throughout their forties--at least.

I'm going with my standard for breast cancer screening: you're at risk if you have breasts!

But it worries me terribly that certain "evidence based" standards may ultimately become the justification for providing less care to people who need it!

In my practice, I  use "anecdotal medicine" in addition to "evidence based " medicine. By that I mean, if I have personally seen a situation that doesn't quite follow the norm, it's logged into the data base of my brain. As an example, few people would agrue that a spiral CT is a requirement to rule out a pulmonary embolism or clot in the lungs with an oxygen saturation level of 100%. But I've seen it! So I can't ignore it when I evaluate a patient with a recent travel history, and pleuritic chest pain (pain at the apex of a deep breath).

Likewise, we trust our "gut level assessments," too. How often I've been glad I did! What is intuition, after all, if not a composite of verbal and non-verbal cues, a melange of past training and in-the-trenches experience?

Physicians struggle against many forces in trying to provide good care for our patients. Health insurance companies provide many hoops for us to jump through. We are often asked to write letter after letter to approve a drug for a patient that is not on the company's formulary.

A great example: a number of years ago, we had a patient in our practice who struggled with very brittle diabetes. She - like many diabetics - suffered with gut motility problems, and it wasn't uncommon for her diabetic gastroparesis to lead to a cycle of vomiting and dehydration that would inevitably land her in the hospital. One of these hospitalizations resulted in such a severe acid/base imbalance that she had to be in the ICU on a ventilator for days. Retrospectively, I believe we might have aborted the whole nightmare for the patient - and reduced costs for all concerned - by having a potent anti-nausea drug, ondansetron, on hand.

I thought it would be logical for the patient to have some available - to use with medical guidance - even on the way to the E.R. So, I wrote a presscription. Unfortunately, the drug was non-generic at the time. No amount of logical letter writing would nudge the insurance company to allocate the $150 medication!

The company "preferred " to foot the bill for thousands of dollars  for later hospitalizations, rather than approve a non-formulary drug!

Similar situations - though probably less dramatic - arise daily. I'll tackle insurance more on another blog day.

So, for me, it all comes down to the practice of "Golden Rule Medicine:" what kind of care would you provide if you or your loved one were the patient?  And if it's not logical, it's probably not the best medicine!

Take care. Linda Gromko, MD

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