How Evidence-Based Medicine Has Influenced The Decision-Making Of Doctors
"Years ago, one of the books in the Curious George series told a thinly-veiled story of when the monkey had an operation that was followed by ice cream. Recently, Sound Medicine's Dr. Aaron Carroll cited that tale about tonsillectomies in his column for the New York Times' online publication Upshot. His point: How evidence-based medicine changed how pediatricians decided which children needed to have their tonsils removed," says host Barbara Lewis.
Carroll: There's a real tension these days where people are starting to fight back against the idea that we need to use science-and-evidence-based medicine to to tell us how to practice. A lot of this comes down to people's rebellion against what we call guidelines or the idea that we can standardize care for certain populations. It's a real tension between people that think medicine's an art and people that think medicine is a science. And there are lots of doctors that have very large disagreements as to how this is practiced. But what I was trying to illustrate with the tonsillectomies, was that Jack Wennberg—who is now a very famous epidemiologist but when he started doing this work, this was a very new field and it was only decades ago—he looked in Vermont and he found that two neighboring towns had incredibly different rates of tonsillectomy. In one town, something like 70 percent of kids would have had their tonsils out by a certain age. And the other town, less than 20 percent. And they truly bordered each other. And he made the point that if he had just moved a couple hundred yards away, the likelihood of his child having a tonsillectomy went way up and it was not because there was any difference in the children, or any difference in disease, or any difference in outcomes. It was just that the people practiced differently and there wasn't data to show that this was the case. And when he presented this data to doctors who did way more tonsillectomies, they started to do less and they started to actually come up with criteria for how to define if a child should have a tonsillectomy. And when I was a kid, everyone had tonsillectomies. They were very, very common. But these days, they are quite rare. They are making a little bit of comeback because of apnea, but the idea that every child is going to have their tonsils out and that we need kids books to explain how this is going to work is much rarer. That's because we started to recognize that for certain populations and certain procedures we could set rules to determine who should get them and who shouldn't. It would save us money and it often led to better quality.
Lewis: Do you think physicians are a little more skeptical about guidelines?... I also remember as an adult, every child I knew had ear tubes.
Carroll: Yep, and there's been some pushback on that, too. Part of it is that we're starting to try to use evidence and research methods and quality assurance to see what actually happens to people. We've seen that often huge variations of care exist across the country and we're not seeing huge outcome improvements by doing more. So there have been guidelines and attempts to try to standardize care which has shown that we can reduce spending and we can also improve quality. Part of the problem is that a lot of doctors don't even know the guidelines exist. And in the piece I cite a study that talks about the percent of pediatricians that know various guidelines exist and it's somewhat shocking to see how few physicians know the guidelines exist. And even when they know they exist, the majority refuse to follow them because they think it's too cookbook, or their patients don't apply, or somehow they don't work, or they know better. And its a problem. Part of the problem is that everybody assumes it's an all-or-nothing thing. And it's important to recognize that guidelines aren't about everybody, but guidelines should set forward specific instances, for certain patients with certain criteria, we know what's best and we figured that out. The art of medicine comes in recognizing which patients don't fit into the guideline, which patients are different because they have a different history or because some other factor which the guideline doesn't take into account makes it so that it doesn't apply to the patient. Physicians are still necessary, but they could still learn quite a bit from evidence-based medicine.