Why I Don’t Adhere to Evidence Based Medical Care
My concierge doctor and I the other day were going over the results of my latest blood test, which he insists that I get with some regularity.
My cholesterol was fine. Free testosterone was perfect. But I was below where I need to be on vitamin D. Ditto for the DHEA vitamin…
Wait a minute. Testosterone? No, free testosterone. Okay, where is there any randomized controlled trial showing that free testosterone is good for your health? The ones that I know of are not much help. And there probably won’t be others any time soon. Even if they get around to another clinical trial, I may not pay any attention to it. More on that below.
On my own
Why should you care? Because we are about to enter a world in which health insurers will only pay for procedures and drugs that are strictly evidenced-based. In fact we are about to enter a world in which doctors will be encouraged to reflexively practice evidence-based medicine for all patients ― regardless of who is paying the bill.
This will have consequences. Just about everything my doctor and I were doing the other day probably violates evidence-based guidelines, including ordering a blood test on an otherwise healthy patient.
As for free testosterone, there is a book on it written by Abraham Morgentaler, a professor at Harvard Medical School. Dr Morgentaler’s bio describes him as a “medical maverick” and a “pioneer” in men’s health, which is another way of saying he doesn’t practice mainstream medicine.
But remember, every advance in medicine started with someone doing something out of the ordinary, something different, something no one else was doing.
If you insist on only employing therapies that are evidence-based, you will only get access to many useful therapies years — or perhaps decades — after other patients have befitted from them.
What about vitamin D? Actually there have been a number of trials with it and it looks like it’s good for you. Unfortunately, there is no evidence-based guideline for testing for vitamin D deficiency, which of course is what my doctor and I did. If your insurer is telling your doctor what to do, odds are you will never know whether you are vitamin D deficient.
There have also been trials with DHEA and they are positive, but probably not sufficiently so for your insurer to pay for it and certainly not enough for your insurer to approve screening for DHEA deficiency.
There have been trials on vitamins as a whole and the results haven’t been good. This, despite the fact that Prof. Bruce Ames (University of California at Berkley) has found striking effects of vitamins in rodent studies. Like Bruce Ames, my doctor believes in vitamins.
This brings us to the whole problem with much medical research. Suppose we conduct a clinical trial on eating peanut butter — just to see what difference it makes. And low and behold we find that there is no significant effect for 99 diseases, but peanut butter eaters have significantly lower risk of Parkinson’s disease.
There are three problems with this finding. The first is called “data mining.” If the distributions are normal, statistics teaches us that about 5 percent of the time we are going to find a significant effect, even though the relationship is entirely spurious. When you hear the term “95 percent confidence interval,” that normally implies we are 95 percent confident the relationship is real. Here is the flip side of that: if we are data mining — searching for anything significant among hundreds of variables — we are going to find spurious relationships as well.
The second problem is that this is testing without theory. There is a statistically significant relationship between the cock crowing and the sun rising, but without any theory relating the two we cannot conclude that the former causes the latter.
Finally, our peanut butter test left out variables that we know are important — including the role of genes. (We didn’t ask the participants if there was a history of Parkinson’s in their family.)
As I have noted before, most medical research would be rejected if the standards of the economics journals were applied.
What should insurance pay for? I don’t have a problem with evidence-based insurance. That’s probably a good way to keep premiums low and shield us from the cost of other people trying out every cockeyed claim that comes their way.
But it is advisable for each of us to have a Health Savings Account, so that we can use our own judgment and make our own choice’s when it appears in our interest to do so.
Perfect song pairing.
“But remember, every advance in medicine started with someone doing something out of the ordinary, something different, something no one else was doing.”
Good point. I’m sure we’ll see medical advances stagnate because of our health care change.
It’ll be interesting to see how the whole thing plays out, but I have a suspicion that many people will get hurt.
Also, I’d like to see more mavericks like Dr. Morgentaler, but I’m sure we’ll see less.
It is amazing how little people (even smart people) are able to understand the three problems that you enumerated. Many foolish opinions are based on misinformation and misunderstanding.
That is my experience as well. Everyone has an opinion on something that they don’t know much about. A deluge of misinformation is hard to overcome.
This is a really tough one here…. we should trust what our doctors are doing, but there are too many outside influences that make us wonder why they give us so many tests (if we are more or less healthy), why they focus on testosterone (seems like a bit of a fad), and tell us we are deficient in vitamin D (my doctor told me that a few years ago). Just does not make any sense for doctors to do all of this.
Exactly, we need less rigidity on more personalization. Unfortunately, we are moving in the wrong direction.
Is there a way we can find evidence based doctors these days?
Although I personally think there’s merit to checking male hormones, the science is basically unproven. Even though I think male hormones are important, there is a host of other minerals, supplements, herbs, micro nutrients, etc. that may be worthless. I don’t expect Blue Cross or Aetna to pay for all the DHEA and free testosterone testing and therapy. The information illustrated above is precisely why people need to control some of their own health care dollars. You can no longer use your HSA or FSA for over-the-counter supplements, which is unfortunate. However, people making their own decisions is why patients need to be able to have some skin in the game. If third-party insurers are paying our bills, they will have the authority to make decision we may not agree with. But if third-party insurers are only insuring us against catastrophic problems, then we need to step up and take control of our day-to-day health and wellness needs.
It may come as a shock to many, but only about 30% (and that’s being kind) of medicine is evidence based.
So what of all the ‘other medicine’ clinicians practice? They likely won’t practicing only evidence based medicine because their revenue would fall through the floor.
The other important aspect that we are beginning to understand is that individual biology plays an important role. That’s why medicine is a practice. We don’t have the necessary information for every situation and condition.
Perhaps this explains ‘failed’ drug tests. Maybe they aren’t failed at all, for certain slices of the population.
Therein lies a great conundrum. If we are able to determine with greater reliability what will (will not) work for a particular patient, will drug companies actually invest in the research knowing that only a relatively small percentage of people will be positively impacted by the new drug?
Of course, others will avoid the harmful side effects of ineffective drugs.
They won’t be able to recoup the research costs across the relatively small affected population…
The problem with John’s article today: EVERYTHING is evidence based. Dr Morgtentaler uses some evidence. Other physicians use different. They simply value the facts differently (the old fact-value distinction).
Without evidence, medicine is witchcraft. I suppose even with evidence, much of modern medicine is still witchcraft: treatment variation for example. Wennberg’s studies of mastectomy rates in Rapid City SD, for example.
I, for one, find the ‘evidence’ for most of this stuff – screening tests, potions, preventive meds – remarkably underwhelming and something that I, as a policy holder, don’t want my carrier to pay others for. Jacks up my rates and probably generates more harm than benefit, meaning ultimately higher premiums.
If John wants to blow some of his own after tax $ on this junk, so ahead.
But I’m not sure I want the gov’t to subsidize through HSA. Again, that’s my dough going into the subsidy.
On balance, I’d prefer more bridges and railroads with my tax dollars, not subsidies for the vitamin, pharmaceutical and screening industries based on such flimsy evidence.
Evidence based protocols at the PCP/PCMH layer should certainly be somewhat flexible as the primary role of the PCMH in population health is wellness and detection of any clinical issues as early in the disease state as possible. Provider inituition is a critical element of the care equation and eliminating this would be a case of penny wise pound foolish.
That said, the body of medical knowledge is now so vast that no single physician can stay abreast of best practices across the board. If healthcare in the US is to evolve beyond it’s designation as the “world’s largest cottage industry” where every provider is free to makes it up as they go along we need to adopt evidence based protocols as standard operating procedure. Providers remain free to adjust care plans to fit the circumstances of each patient however at least they start out with something that reflects currently understood best practices.
I don’t think there is anything wrong with evidence-based practice. In fact, in the long run, it should improve medical practice and ingenuity. However, I don’t think it’s good to impose it, either.
John, I think you should start changing the term ‘insurance company’ to ‘Federal Gov’t. Nearly 20k pages of regulations – the insurance companies do almost NOTHING other than what the Gov’t tells them to.
Oct 1st and the Exchanges kick off, many are not ready, tested, secure, benefits you didn’t ask for but have to pay for, huge premiums hikes for the young. I’m an insurance broker and when I get complaints I’m responding – call #Comments: 202-456-1111 Switchboard: 202-456-1414, the White House, because they regulated everything.
John:
You write: “If your insurer is telling your doctor what to do, odds are you will never know whether you are vitamin D deficient.”
Insurers don’t tell doctors what to do or not to do. They just tell them what they will or will not pay for. What is wrong with that?
If you and your doctor thinks it is good to have a vitamin D test — or to drink a Coca-Cola, for that matter — who is stopping you from buying the test with your own money?
So what is your complaint?
Uwe, your statement to John is only sometimes true. Insurers have told doctors what to do and what not to do.
Well, if the insurer is going to make restrictive decisions, which I think is probably necessary, then people need to have Heath Savings Accounts that are liberally funded and they need to know in advance that they are going to need these accounts to obtain care that the insurer is going to deny.
Not sure ‘have a liberally funded HSA’ follows from ‘carriers make restrictive decisions’.
Why not pay with after tax dollars? That way I don’t have to subsidize your decisions.
While insurers may not tell physicians what to do (yet), health plans certainly do, Medicare does, and Medicaid is trying. Controlling how physicians practice is the holy grail of pay for performance, and I’d wager that a lot of patients don’t have any idea how it is affecting their treatment.
The problem, of course, is that evidence-based medicine as currently institutionalized is a school of thought that considers some kinds of evidence more equal than others. To make a long story short, if it isn’t from a randomized study, it basically doesn’t count. For a visual representation, see the cute little pyramid in the post on hormone replacement http://healthblog.ncpathinktank.org/how-evidence-based-medicine-went-wrong-on-hormone-replacement/
That pyramid is everywhere in various allied health professional courses.
The cute little pyramid is not especially scientific. Observation provides evidence. So does using existing theory to project how a system might work and coming up with an experiment to either prove or disprove the hypothesis. Examples abound: Harvey didn’t discover the circulation of the blood through a RCT, and chemists somehow managed to discover the periodic table without them.
That doesn’t mean that those two discoveries were, as an earlier comment put it, “witchcraft,” or that medicine without RCTs will have to rely on crystal balls.
Since the standard for “evidence-based” medicine is a double blind clinical trial, there is very little done in medicine that qualifies. Is it a good idea to suture a wound? The only way to really know would be to have a test group whose wounds are sutured and compare them to a control groups whose wounds are left unattended. Same with broken bones or infection control. None of this has been put to the double blind test, so obviously none of it should be done.
John,
I love your work but you are WRONG on Vit. D!
Look at the Endocrine Society’s clinical guidelines of Vit. D deficiency available on the web site.
https://www.endocrine.org/endocrine-press/clinical-practice-guidelines
There ARE clinical guidelines. Remember Medicine is still and will be an art. Remember lack of evidence is not evidence. Science is a fluid discipline, medical science in particular. The evidence based practice I did 10 years ago is malpractice now!
I am an advocate for my patients and will adhere to any guidelines (we have new pap smear guidelines just out this year dramatically changing the frequency) but payers will not be able to hide from the reality that lack of a guideline supports nonpayment. Non adherence is where the money will be saved.
Uwe is correct. On paper, insurers do not tell doctors what to do, merely what they will pay for. Doctors and patients are free to pursue uncovered tests and treatments as long as the patient is willing and able to pay. That is the hooker. Whereas John’s supplements are generally affordable, mainstream tests and medicines, not to mention physician and hospital care are generally priced at several times the rates negotiated by insurers. For example, my recent lab bill documents prices 7-12 times the Medicare reimbursement. Functionally, without insurance,these are unaffordable. Thus, in reality, insurance coverage does dictate medical care except for the very wealthy. Only where there is a marketplace outside of insurance coverage, e. g. cosmetic surgery, supplements, concierge care, and walk-in clinics does the patient obtain objective pricing. Maybe greater usage of HSA’s would drive mainstream medicine in this direction. That would be welcome and would allow patients and their physicians more flexibility without negating the value of evidence-based practice. Of course, this would mean that the medical care industry would have to develop transparent pricing, something that it has resisted.