The deep irony is that advocates of Obamacare declare that "evidence based medicine" will lower costs and improve care without presenting any actual "evidence." - D.M. Cassel

One of my earliest posts(7/31/10) discussed how outlier events had an enormous impact on how doctors practiced medicine. The prior two posts have given additional reasons why "Evidence Based Medicine" remains a utopian dream of a few academics and reformers. Today I will mention still another reason "Evidence Based Medicine" doesn't work in the real world, people want their diseases treated, and doctors want their problems solved.

In actual practice, primary doctors take care of what they can, but commonly refer many patients for specialty care. Specialists of all types get their patients, and derive their income from these referrals. Without these patients, many surgeons, neurologists, kidney doctors and many others would have little work. Competition for these referrals between specialists is a key driver to how medicine is practiced. Even in managed care practices and academic centers primary care doctors have choices about whether and who to send their patients for additional care.

These family doctors care about what happens to their patients once they are sent to specialists. How well people are treated and the eventual outcomes determine whether they will send more patients in the future. Needless to say, those specialists that do the best job satisfying both the patients and the referring doctors thrive. Enough negative feedback or poor results can ruin a medical career. In actual practice, this motivation to succeed is a powerful one, which is far more important in determining how medicine is practiced than "scientific evidence".

A typical example might be a primary care doctor referring a someone with persistent back pain. Conservative treatment and anti-inflammatory medications have not worked. The patient and his doctor have both become frustrated and angry. The orthopedist sees the patient, in pain, not responding to therapy. MRI scans show a degenerated disc which may or may not be responsible for the problems. Both the referring doctor and the patient himself wants something done now. The specialists first choice is to continue pursuing a non-surgical course of action, knowing that eventually the symptoms will recede, although it may take two years. On the other hand, if he operates now, the symptoms will improve, the patient and doctor will be satisfied, not to mention the surgical fees. "Evidence Based Medicine" aside, the choices become pretty clear.

The deep irony is that advocates of Obamacare declare that "Evidence Based Medicine" will lower costs and improve care without presenting any actual "evidence" it will work. Good intentions and hopeful fantasies may work on TV dramas and the halls of Congress, but in the real world, we deserve better.