Why Doctors Hate Science

[Professor Yaffle]

Thank God doctors in the United States are free to treat patients as they deem best, free from interference by faceless bureaucrats. If bureaucrats were in charge, physicians might have to prescribe the newest hypertension drugs as a first-line therapy, do MRIs to diagnose back pain and give regular Pap tests to women who have had total hysterectomies. Oh, wait—they do. All these medical practices are common, despite rigorous studies showing how useless or wrongheaded they are. Definitive studies over many years have shown that old-line diuretics are safer and equally effective for high blood pressure compared with newer drugs, for instance, and that MRIs for back pain lead to unnecessary surgery. And those Pap tests? Total hysterectomy removes the uterus and cervix. A Pap test screens for cervical cancer. No cervix, no cancer. Yet a 2004 study found that some 10 million women lacking a cervix were still getting Pap tests.
It's hard not to scream when you see how many physicians, pharmaceutical companies, medical-device makers and, lately, hysterical conservatives seem to hate science, or at best ignore it. These days the science that inspires fear and loathing is "comparative-effectiveness research" (CER), which is receiving $1 billion under the stimulus bill President Obama signed. CER means studies to determine which treatments, including drugs, are more medically and cost-effective for a given ailment than others. A study in February in the journal Lancet, for instance, compared treatments for severe ankle sprains, concluding that a below-the-knee cast is superior to a tubular compression bandage. A 2006 study of schizophrenia drugs found that old-line antipsychotics were as effective as pricey new ones.
<snip>

http://www.newsweek.com/id/187006

 

[macdoc]

How much of this is

Cover my ass?

Profit driven?

Ignorance of current best practice?

In Canada the latter would predominate and there are programs to enhance physicians skills.

 

[paximperium]

My anecdotal experience:

How much of this is

Cover my ass? 50%

Profit driven? 10%

Ignorance of current best practice? 40%

 

[fls]

http://www.newsweek.com/id/187006

Do you know who she's reacting to?

Linda

 

[JJM]

I haven't followed this; but here are some opinions:

http://scienceblogs.com/insolence/2009/03/doctors_hate_science_more_like_sharon_be.php

http://www.sciencebasedmedicine.org/?p=381

 

[jimtron]

Thank God doctors in the United States are free to treat patients as they deem best, free from interference by faceless bureaucrats.

Ooh, I saw that Twilight Zone episode...

 

[Dr. Imago]

I couldn't have penned better, more succinct answers myself than the first two replies below the article...

Here's another thought, the "useless" or "wrongheaded" medical testing or expensive drug therapies ordered by physicians can occasionally be attributed not the the physicians "hatred of science" but the the litigious nature of our society. When a patient comes into the doctor's office demanding the "new medication" they saw advertised on TV, no amount of education can effectively combat mass media. When patients demand an MRI for their back pain, when the simple truth of their being overweight or stress injury is the answer, physicians hands are tied. The American public for all it's glory is the chief evil of the high cost of health care in this nation. The misuse of the nation's emergency rooms for the convenience factor for non-emergent conditions is a gross misuse of resources. But again because of the litagious nature of the American public you can't be told to go home, take 2 aspirin and call your doctor's office in the morning.

Just a thought: personally, I think this article has the depth of thought atributable to most mass/mainstream-media. Issues distilled to an easily digetsible sound-bite (or web blog). Heck, if we wanted to do "comparative medicine", perhaps we should compare two things:

The Institute of Medicine report and other articles state that between 44,000 and 195,000 preventable deaths occur at the hands of healthcare professionals in this country every year.

The Department of Justice reports approximately 30,000 homicide deaths in the country from firearms.

Therefore, a superficial comparative analysis suggests that we should be banning doctors, not handguns.

~Dr. Imago

 

[Ivor the Engineer]

Of course, it has nothing to do with the fact hospitals and many medical professionals make more money from providing unecessary healthcare.

No, let's just assume those in the medical profession are not influenced by incentives.

Anybody want angioplasty and a stent fitting for their chest pain?

 

[Dr. Imago]

Of course, it has nothing to do with the fact hospitals and many medical professionals make more money from providing unecessary healthcare.

No, let's just assume those in the medical profession are not influenced by incentives.

Anybody want angioplasty and a stent fitting for their chest pain?

You'd be surprised how little physicians, at least in academia, know about how much particular tests and procedures cost the patient. Most are paid a flat salary, and receive no specific and direct remuneration for performance.

~Dr. Imago

 

[Travis]

Not having any health insurance I have to pay cash for all my procedures, medicines and doctor visits. I always ask what something will cost and the doctors usually have no idea how much any one thing is. They are often quite surprised how much, or little, some things cost when they look into it for me.

 

[paximperium]

Of course, it has nothing to do with the fact hospitals and many medical professionals make more money from providing unecessary healthcare.

No, let's just assume those in the medical profession are not influenced by incentives.

Ivor, can't you at least hide your bias a bit better?
I find your bigotry against the medical profession one of the most unintelligent I've ever seen.

There are many issues with medicine. Incentives are not one of the major problems. Butt protecting and just intellectual laziness is more a problem.

Wanna change this overuse of procedures? Change the reimbursement scale to pay more for using the brain than for procedures.

Anybody want angioplasty and a stent fitting for their chest pain?

If it meets criteria and I have heart disease most definitely. Did you have a point?

 

[paximperium]

You'd be surprised how little physicians, at least in academia, know about how much particular tests and procedures cost the patient. Most are paid a flat salary, and receive no specific and direct remuneration for performance.

~Dr. Imago

The entire County Hospital I work in is salaried. They actually get no benefit in seeing more patients or doing more procedures...the opposite is true actually but we still do tons of colonoscopies, mammograms, Paps, caths etc.

 

[RationalVetMed]

Of course, it has nothing to do with the fact hospitals and many medical professionals make more money from providing unecessary healthcare.

No, let's just assume those in the medical profession are not influenced by incentives.

Anybody want angioplasty and a stent fitting for their chest pain?

If that was the case then presumably more unnecessary procedures would be done in places where doctors were on performance related pay. Is there any evidence for this?

Yuri

 

[JWideman]

Heh. My doctor, fully aware that I have pins in my hip, tried to send me for an MRI.

 

[paximperium]

If that was the case then presumably more unnecessary procedures would be done in places where doctors were on performance related pay. Is there any evidence for this?

Yuri

Actually there is. Patient's with better insurance will tend to get more procedures compared to those with lousy insurance.

The definition of "unnecessary" is the contention.

 

[paximperium]

Heh. My doctor, fully aware that I have pins in my hip, tried to send me for an MRI.

If the pins were placed within the last 2 decades, they are titanium and can be put through an MRI.

 

[RationalVetMed]

Actually there is. Patient's with better insurance will tend to get more procedures compared to those with lousy insurance.

That doesn't necessarily support Ivor's assertion; patients on insurance isn't the same as docs being on performance related pay.

My take on your insured patients statement would be that insured patients have less financial constraints therefore receive better healthcare than someone who is counting the pennies (or nickels or dimes or whatever passes for currency in the colonies these days) .

Yuri

 

[T.A.M.]

Here are my thoughts on her article. I will only quote the bits I have a problem with, or need to comment on:

If bureaucrats were in charge, physicians might have to prescribe the newest hypertension drugs as a first-line therapy, do MRIs to diagnose back pain and give regular Pap tests to women who have had total hysterectomies. Oh, wait—they do.

She is generalizing here. There are times when an MRI is needed to diagnose the cause of the back pain. There are women, who had their hysterectomy done years ago, where in some cases part of the cervix may have been left in. As well, some doctors will do Vaginal Vault smears to screen for vaginal cancers (rare). Overall, I agree with others, that if these are done to excess (she is commenting on the USA, and I am a Canadian GP), it is through CYA and lack of knowledge on current diagnostic and therapeutic guidelines.

Definitive studies over many years have shown that old-line diuretics are safer and equally effective for high blood pressure compared with newer drugs

I would say diuretics are AS SAFE as the newer drugs, and in most cases, SUPERIOR in terms of blood pressure reduction. However, what she fails to explore, are side effect comparisons (ARBs have way fewer side-effects compared to older meds such as diuretics and B-Blockers). She also fails to look at cases beyond the otherwise normal Hypertensive. For instance, with the diabetic, the benefits of an ACE inhibitor or a Calcium Channel Blocker wrt Renal Protection have to be considered.

MRIs for back pain lead to unnecessary surgery.

Sometimes, how often is the question, and based on what? If there is a surgically correctable lesion, then it is up to the orthopedic surgeon to inform the patient, and to present the options, and their repercussions.

And those Pap tests? Total hysterectomy removes the uterus and cervix. A Pap test screens for cervical cancer. No cervix, no cancer. Yet a 2004 study found that some 10 million women lacking a cervix were still getting Pap tests.

See my above comment earlier. However, even what I had said, cannot account for this many unneeded pap smears. Interesting to see how many were done at the suggestion of the physician versus the insistence of the patient.

A 2006 study of schizophrenia drugs found that old-line antipsychotics were as effective as pricey new ones.

Once again, side effects in the two drug classes are not considered. (compare rates of occular-gyric crisis with haldol versus Zyprexa for instance)

You might attribute Coburn's rant to his small-government ideology, but I say blame his profession—not politics but medicine. Doctors have long resisted having science guide their practice.

Absolute crock based generalization, unfounded opinion, poppycock.

That's obvious from the disparity in clinical practices from one region of the U.S. to another,....the enormous disparity in how doctors in different regions treat the same condition reflects medical culture, not medical science. Docs influence each other—"How would you handle this?"—at the local medical association and even on the golf links. "Doctors want to do what their colleagues are doing,"

There is an element of truth to the above. There is no doubt that medicine is clinically taught based on the mentoring and peer consensus, but there are standards, their are guidelines, not just based on what your colleague is doing, but based on what experts recommend, and based...yes...ON science.

In one infamous case in the mid-1990s, a federal agency concluded that spinal fusion doesn't help back pain, a decision that threatened insurance coverage for it. Surgeons, who stood to lose piles of money, got Congress to decimate the agency's budget, forcing it to pull back from making recommendations.

"a federal agency"? Well which one, and based on what?

A younger generation of doctors, perhaps more comfortable with science and clinical studies, is embracing CER. Dr. Kevin Pho, who practices internal medicine in Nashua, N.H. (and blogs at kevinmd.com), says that at least once a day he has a patient for whom there are numerous treatment options—the new diabetes drug or an old one? "An unbiased source of data, not drug companies, could really help us in primary care," he says. "There have to be allowances for individual differences, but you need standards." What a concept.

I would agree that younger physicians are more eager to embrace evidence based medicine, etc... but who do you think are conducting the studies that produce the evidence?? Not just young doctors.

Any way, some of my thoughts.

TAM

 

[Ivor the Engineer]

If that was the case then presumably more unnecessary procedures would be done in places where doctors were on performance related pay. Is there any evidence for this?

Yuri

Yes.

http://cat.inist.fr/?aModele=afficheN&cpsidt=15075159

This paper investigates on the existence of physician-induced demand (PID) for French physicians. The test is carried out for GPs and specialists using a representative sample of 4500 French self-employed physicians over the 1979-1993 period. These physicians receive a fee-for-services (FFS) payment and fees are controlled. The panel structure of our data allows us to take into account unobserved heterogeneity related to the characteristics of physicians and their patients. We use generalized method of moments (GMM) estimators in order to obtain consistent and efficient estimates. We show that physicians experience a decline of the number of consultations when they face an increase in the physician: population ratio. However this decrease is very slight. In addition physicians counterbalance the fall in the number of consultations by an increase in the volume of care delivered in each encounter. Econometric results give a strong support for the existence of PID in the French system for ambulatory care.

http://www.esri.go.jp/en/archive/e_dis/abstract/e_dis147-e.html

Percutaneous Transluminal Coronary Angioplasty, henceforth (PTCA) for patients with acute myocardial infarction (AMI)-a high-tech treatment-is more frequently used in Japan than in other developed countries. This paper adopts the two-phase model to examine whether the high PTCA use is driven by the self-interest of physicians, or by behavioral character. After controlling for a patient's detailed characteristics, we found that increases in the relative numbers of hospitals and physicians are significantly related to physician-initiated expenditures and the effect is higher for high-tech treatments. The results based on municipal-level aggregated data also support this conclusion.

http://www.socialpolitik.de/tagungshps/2007/paper/Juerges.pdf

Using German SOEP 2002 data, I estimate a hurdle model for the effect of district (Kreis-) level physician density on the individual number of doctor visits – accounting for the possibility of simultaneously determined physician density. The paper has four main findings. First, I find no evidence that physician density might be endogenous. Second, conditional on health, privately insured patients are less likely to contact a physician but more frequently visit a doctor following a first contact. Third, physician density has a significant positive effect on the decision to contact a physician and on the frequency of doctor visits of patients insured in the statutory health care system, whereas, fourth, physician density has no effect on privately insured patients' decisions to contact a physician but an even stronger positive effect
on the frequency of doctor visits than for the statutorily insured. These findings give indirect evidence for the hypothesis that in Germany, physicians induce demand for medical services among privately insured patients but not among statutorily insured.

 

[luchog]

I would say diuretics are AS SAFE as the newer drugs, and in most cases, SUPERIOR in terms of blood pressure reduction. However, what she fails to explore, are side effect comparisons (ARBs have way fewer side-effects compared to older meds such as diuretics and B-Blockers). She also fails to look at cases beyond the otherwise normal Hypertensive. For instance, with the diabetic, the benefits of an ACE inhibitor or a Calcium Channel Blocker wrt Renal Protection have to be considered.

That's my biggest peeve with people who whinge on about "expensive new drugs that are no better than the cheap old stuff". Yes, they may be equivalent in effectiveness; but typically have far fewer and less severe secondary effects, particularly with regard to LTU and potential toxicity.