Archive for November, 2009


The Trouble with Evidence Based Medicine

   Posted by: Robert    in Uncategorized

In an interesting article on NRO, Stephen Spruiell talks a bit about a radio program that aired recently on NPR.  The NRO article makes excellent reading and provides a great deal of room for thought.  What most caught my attention in the article was the story of Dr. Dan Merenstein.  His story succinctly captures what I believe is a coming problem in health care which America will need to deal with whether or not Obamacare becomes a reality.  The problem is what to do with evidence based medicine.

To set the stage for the coming discussion, here is the quote from the NRO article describing Dr. Merenstein’s story:

The NPR team produced several stories on how defensive medicine drives up costs, including one about a doctor named Dan Merenstein. As a third-year resident, Merenstein counseled a 53-year-old man on the benefits and risks of getting a PSA screening (a common test for prostate cancer). Merenstein told his patient that he thought the risks outweighed the benefits: False positives are common, follow-ups invasive and potentially harmful. The man declined the test.

The man was later diagnosed with a fatal prostate cancer, a kind that early detection probably would not have helped. He nevertheless sued Merenstein and his residency program. The plaintiff’s lawyers argued that Merenstein shouldn’t have given the man a choice on whether to have the test. “The jury . . . rejected the idea of following the guidelines based on evidence,” Merenstein said. “They took this approach that this thing called evidence-based medicine is just a way to save money, just a way to ration care.”

The verdict left Merenstein alone, but found his residency program liable for $1 million. He told NPR that it’s hard not to see patients as potential plaintiffs. He says he still counsels patients on the potential drawbacks of the expensive, not-always-necessary screening, but he admits that he gives patients a little push by telling them that most people do get the test.

For those new to the term, evidence based medicine (EBM) is a technique for deciding what tests or treatments to offer a patient.  EBM uses the scientific method to identify which procedures are more likely than others to ensure that a patient arrives at a good outcome.  The science of EBM looks to research studies, peer reviewed publications, and experimentation to reach its conclusions, and then publishes those conclusions as guidelines for doctors to use in everyday practice.  The goal of EBM is to increase quality of care and lower costs by identifying treatments that work well, work quickly, have the fewest side effects, and minimize a patient’s risk.  What EBM provides is a recipe for doctors to follow when caring for their patients that has been shown to be scientifically sound.  What EBM does not provide is a guarantee that the recipe is always the right one in every case.

For a society gripped with litigious instincts, EBM represents one of modern medicine’s greatest double edged swords.  On the one hand, the entire point of EBM is to improve the quality of patient care by providing doctors with treatments that are both effective and affordable.  On the other hand, EBM invites a variety of legal questions which we as a society are going to need to deal with.  Should doctors be held liable for bad patient outcomes when they do not follow EBM prescribed treatments?  Should following EBM treatments create a presumption, rebuttable or not, that a doctor acted appropriately and should be held immune from suit?  Should insurance companies pay for non-EBM procedures?  What happens if the answer to both of the latter two questions is “no”?  There are many more questions, but that covers the flavor of what sorts of things that we as Americans should begin asking ourselves.

In my view, doctors should be guided by EBM, but not constrained by it.  Legally, it would be fair to create a rebuttable presumption that EBM treatments are appropriate, but leave doctors responsible for determining whether or not the EBM treatment applies.  Doctors should certainly be permitted, if not encouraged, to depart from EBM in situations where their professional judgment suggests that a different course of action is more appropriate.  Doctors should, however, be required to know exactly what they are doing and why; avoiding an EBM treatment simply because the doctor does not care for it would not be a valid line of reasoning.

As patients, we owe it to ourselves to ensure that we receive the best possible care.  It is ultimately up to each of us to make sure that doctors have made the best decisions in our particular case.  We should feel comfortable asking doctors if their treatment is evidence based, and doctors should feel comfortable explaining why not if the answer is no.


Climate Change, Overpopulation, and Darwin

   Posted by: Robert    in Politics

I wonder if it is unfair to use the rules of evolution against the left.  For all the confusion the claims say conservatives have about how species change over time, nowhere is ignorance of the forces which drive population changes more on display than in today’s opinion section of the New York Times.  Thomas Friedman invites us to believe that conservatives “believe the world is going to face a mass plague, like the Black Death, that will wipe out 2.5 billion people sometime between now and 2050.”  He apparently feels that conservatives “believe all these things because that is the only way their arguments make any sense.”  His proof, however, entirely ignores the way population change works.

But there are two other huge trends barreling down on us with energy implications that you simply can’t deny…

The first is that the world is getting crowded. According to the 2006 U.N. population report, “The world population will likely increase by 2.5 billion … passing from the current 6.7 billion to 9.2 billion in 2050. This increase is equivalent to the total size of the world population in 1950, and it will be absorbed mostly by the less developed regions, whose population is projected to rise from 5.4 billion in 2007 to 7.9 billion in 2050.”

From this quote right here we get to see where the 2.5 billion person figure comes from.  It’s based on a UN projection of population growth and the apparent belief that the world cannot support any more people than are currently occupying it today.  As I see it, this has two major problems.  The first is that there is no indication that the Earth cannot support any more humans even under our current technology.  The second is that Mr. Friedman counts as dead about 2.5 billion people who do not exist and may never exist.

But be those problems as they may, there is nothing so terribly sinister at work as some deep belief in a mass kill-off of a significant chunk of the human population.  The forces underlying evolution apply a downward force on the growth rate of every species.  As the population of a species increases, the odds of survival for any individual member tend to decline.  Natural predators are attracted to dense concentrations of prey, competition for mates intensifies, and resources become harder to find.   These downward forces gradually eliminate the less adapted members of the species until the population reaches an equilibrium state.  The result is not a mass killing, but a gradual pruning of the family tree.

This process, of course, occurs in nature every day and nobody thinks much about it.

Mr. Friedman is hardly the first to have brought overpopulation fallacies to bear for political ends, nor is he likely to be the last one to make such an error.  To the extent that green technologies require burning our own food as gasoline, the net increase in hunger will serve not to prevent the 2.5 billion “deaths,” but to accelerate them.  What’s more, even the greenest of technologies will serve only to kick the can down the road; the human population will eventually reach its capacity for growth.

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