Re: "Half of what physicians do is wrong," ...
- From: Herman Rubin <hrubin@xxxxxxxxxxxxxxxxxxxx>
- Date: Wed, 31 Aug 2011 17:19:59 +0000 (UTC)
On 2011-08-30, George Conklin <nilknocgeo@xxxxxxxxxxxxx> wrote:
"Herman Rubin" <hrubin@xxxxxxxxxxxxxxxxxxxx> wrote in message
On 2011-07-17, george conklin <nospam@xxxxxxxxxx> wrote:
"rpautrey2" <olivercrangle23x@xxxxxxxxx> wrote in message
I have no idea what was written in the article referred to.
There were no indicated quotes from it ..n Conklin's article.
Health Care Myth Busters: Is There a High Degree of Scientific
Certainty in Modern Medicine?
Two doctors take on the health care system in a new book that aims to
arm people with information
By Sanjaya Kumar and David B. Nash | Friday, March 25, 2011 | 28
DO DOCTORS HAVE GOOD DATA?: An excerpt from Demand Better! Revive Our
Broken Health Care System by Sanjaya Kumar and David B. Nash
Image: Second River Healthcare Press
Editor's Note: The following is an excerpt from the new book Demand
Better! Revive Our Broken Health Care System (Second River Healthcare
Press, March 2011) by Sanjaya Kumar, chief medical officer at
Quantros, and David B. Nash, dean of the Jefferson School of
Population Health at Thomas Jefferson University. In the following
chapter they explore the striking dearth of data and persistent
uncertainty that clinicians often face when having to make decisions.
Myth: There is a high degree of scientific certainty in modern
Of course not; the amount of certainty needed does not exist
in this type of biological problems. But doctor's seem to
take the attitudue that they KNOW what to do.
Herman, what doctors have to do by law and tradition is to make reference to
"procedures." Thus is A happens, the procedure is to do B. Whether it
works is another issue completely. That is where the subjectivity comes in.
If you do a complete blood count there is always going to be something to
"investigate" even if there are no complaints or symptoms. Is THAT science?
Have you ever seen me argue that "medical tradition" should be
followed? I have always stated that the patient should be the boss,
not the doctor, and more should be allowed, not less.
But as to whether that is "science", of course not. Doctors in their
practice are rarely involved in science, but rather in "engineering".
Doing a complete blood count even if there are no complaints or
symptoms is part of preventative medicine, to find the problem before
it gets large. This IS considered sound.
"In America, there is no guarantee that any individual will receive
high-quality care for any particular health problem.
Nor is there anywhere else in the world.
You forgot to apply statistics to your response Herman. Are more likely to
get high-quality health care in the USA? You seem to think so. Results say
other systems do better, on the average. Guarantee? No meaning.
Which criteria? Are they valid? Comparing the incidence of
Type 2 diabetes in the US to that in other countries, for example,
would prove nothing, as there is a huge genetic component. The
same is true for most other overall criteria.
Most of us are confident that the quality of our healthcare is the
finest, the most technologically sophisticated and the most
scientifically advanced in the world.
To quote Abraham Lincoln, "One can fool some of the people
all of the time." But in this case, this is a moderately
accurate statement of the situation.
But there is a wrinkle in our confidence. We believe that the vast
majority of what physicians do is backed by solid science. Their
diagnostic and treatment decisions must reflect the latest and best
research. Their clinical judgment must certainly be well beyond any
reasonable doubt. To seriously question these assumptions would seem
jaundiced and cynical.
The biggest gap in this is that the clinical judgment is beyond
reasonable doubt. The individual patient has individual values,
and the NECESSARILY PROBABILISTIC information which medicine can
provide to the patient must be assessed according to the patient's
values and beliefs. Objectivity in science, alas, cannot exist.
Ok, but when statistical studies come out showing, for example, that
current treatments for prostate cancer do NOT result in longer life
expectancies (at 10 years) the system gets mad, and patients object because
our culture says "do something," even it is expensive and does not work and
results in problems. Values say "do something," and whether it works or not
is not an issue. This is exploited by the system to make tons of money.
I believe that if a prostate cancer is contained and giving no problems
the common treatment is watchful waiting. Otherwise, the cancer is
going to either shorten life or reduce its quality, and hence something
should be done, and one cannot wait until the new treatment is around
long enough to be evaluated. I suspect that in these studies, which are
very unlikely to be double blinded for obvious reasons, it is likely to
be those whose evaluations are worse who have the treatment, in which case
the equal life expectancies are a sign of effectiveness.
The statistical methods needed are high dimensional onws, of which the
medical profession is ignorant.
But we must question them because these beliefs are based more on
faith than on facts for at least three reasons, each of which we will
explore in detail in this section. Only a fraction of what physicians
do is based on solid evidence from Grade-A randomized, controlled
trials; the rest is based instead on weak or no evidence and on
subjective judgment. When scientific consensus exists on which
clinical practices work effectively, physicians only sporadically
follow that evidence correctly.
Better use of statistics is needed. We cannot wait for someone to
spend billions on a clinical trial of the above sort to decide what
to do. Can we take even a thousand infants and carry out a clinical
trial controlling all other variables to find out how to live to a
ripe old age, and wait 80 years before taking any action? Neither
part can be done.
And there is no need for this kind of research, even though some groups have
been followed for many, many years. The AARP study is one such group. But
for specific treatments (such as prostate cancer) it is imperative to do
some good research over a reasonable period, say 10-15 years. And for
women, HRT showed that common practices were increasing breast cancer rates
by a factor of 2, and no one noticed it.
Not surprising; the rate is still low. I have seen an arguments
suggesting that the practice still be continued, as the benefits,
at least in the opinion of some, outweigh the increased risk of cancer.
Medical decision-making itself is fraught with inherent subjectivity,
some of it necessary and beneficial to patients, and some of it flawed
and potentially dangerous. For these reasons, millions of Americans
receive medications and treatments that have no proven clinical
benefit, and millions fail to get care that is proven to be effective.
Quality and safety suffer, and waste flourishes.
Again, some subjectivity, especially on the part of the patient,
is imperative. Other aspects of subjectivity are needed for any
kind of efficiency; this has been shown in analyzing statistical
problems. Other aspects come in.
Is this new?
Only about 50 years old for practical problems.
We know, for example, that when a patient goes to his primary-care
physician with a very common problem like lower back pain, the
physician will deliver the right treatment with real clinical benefit
about half of the time. Patients with the same health problem who go
to different physicians will get wildly different treatments. Those
physicians can't all be right.
The last statement is corrects. But the patient with lower back
pain should be going to a specialist, not the present type of
primary care physician. The primary care physician should allocate,
and use judgment and thinking on the level of a Sherlock.
Questioning the unquestionable
The problem is that physicians don't know what they're doing. That is
how David Eddy, MD, PhD, a healthcare economist and senior advisor for
health policy and management for Kaiser Permanente, put the problem in
a Business Week cover story about how much of healthcare delivery is
not based on science. Plenty of proof backs up Eddy's glib-sounding
With our knowledge of science, this is not surprising.
But physicians are taught to be like this, and also the payers
do not support any costs physicians have in getting better
information. A lawyer looking up old cases charges by the
hour; a physician can charge nothing to search the literature.
Physicians should consult specialists; they do not usually.
Medicine, Herman, runs on procedures, not past research. Lawyers have a
lot more wiggle room. UCR rules medical care. If it is a the usual
practice, the individual physician cannot be blamed for bad results.
So medicine should be redone. Some has been, in that a patient can
refuse treatment, and a physician ignores information from a patient
that certain drugs can have adverse effects at his quite substantial
risk, which is as it should be.
The plain fact is that many clinical decisions made by physicians
appear to be arbitrary, uncertain and variable. Reams of research
point to the same finding: physicians looking at the same thing will
disagree with each other, or even with themselves, from 10 percent to
50 percent of the time during virtually every aspect of the medical-
care process-from taking a medical history to doing a physical
examination, reading a laboratory test, performing a pathological
diagnosis and recommending a treatment. Physician judgment is highly
The late Professor Jerzy Neyman had astronomers look at photographs
which they had previously looked at and get different results. The
same was with physicians looking at X-rays. Not all the time, but
often enough to discontinue chest surveys, as the damage done from
false positives exceeded the benefits. And of course, different
people looking at the same thing see differently.
"Half of what physicians do is wrong," or "Less than 20 percent of
what physicians do has solid research to support it."...It would be
political suicide for our public leaders to admit these truths...Most
Americans wouldn't believe them anyway...
It all is true, but the review ignores the fact that hormone replacment
therapy for women was the sign of "quality" medical care a few years ago,
until it was shown to double breast cancer rates. The brief discussion
prostate cancer treatments is way off, since in the USA the treatments
actually increase deaths 10 years out, although the increase was not
"statistically significant." However, it is correct that the public will
not stand for or believe a large amount of what is in the book.
Science does not advance by data leading to theories. Data can only
decide between the theories which the investigator has in mind. In
many cases, it can cause the investigator to go back and rethink his
theories, but there is always subjectivity.
You are not into philosophy. Read "Modern Science and Modern Man" for a
more complete discussion. But you may be misled because when you have a
large data set, what emerges usually does not conform to theory. In fact,
theory obscures the facts. That is what happened to the HRT studies.
Self-selection, for example, obsured what was going on.
To some extent, I was forced into philosophy be the consideration of
the foundations of statistics, which is rational behavior under
uncertainty of the state of nature. Consideration of what this
implies forces an approach, and imposes restrictions on self-consistent
behavior of the individual. Unfortunately, it also precludes the
existent of self-consistent behavior of society based on that of its
members; we are stuck with this paradox.
A problem which necessarily occurs is that physicians each have their
prejudices, the "organized medical profession" is loaded with prejudices,
the payer must necessarily be trying to reduce costs, and the patient,
who is the only one who really counts, has his own utility and beliefs.
If the patient is the payer, the situation realizes itself, if the
medics are told bluntly, you listen and do not pontificate. Otherwise,
we have major problems.
Well, the system is trying to maximize income too, so the patient has a
real problem saying NO.
Why? I have said NO on many occasions.
But if you make the cost to the patient low, the patient will have
little reason to say NO. Socialized medicine contains the setup to
encourage its overuse.
This address is for information only. I do not claim that these views
are those of the Statistics Department or of Purdue University.
Herman Rubin, Department of Statistics, Purdue University
hrubin@xxxxxxxxxxxxxxx Phone: (765)494-6054 FAX: (765)494-0558
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