Saturday, October 25, 2008

A long letter to the NY Times

I wrote a long reply to an opinion piece in the New York Times today, only to find that they had ceased accepting any further reader comments. In an attempt to have someone else in the world read this thing beside myself, I’ll post it here. The opinion piece in question can be found here.

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As a neurosurgical resident—someone immersed (and sometimes nearly drowning) in our health care system—I take issue with the contention that American health care is the “worst” or provides too little for too much expense. Sure, our system has pitiable faults: we insure far too few, our preventative care lags behind that of other countries, and we devote an onerous proportion of our nation’s GDP to medical care, among other problems. However, this country is the best place in the world to be if you’re sick—and by this I mean really, imminently-likely-to-die sick. We Americans believe in and practice the hail-mary pass, the last-ditch effort that fails most of the time, but every so often pulls off a miraculous victory. That’s a beautiful, unique thing, which you won’t find in the U.K. or Canada. It’s also quite expensive.

In addressing this issue of expense and quality, the authors propose that we somehow fix the health care situation by making health care more like pro sports. If that means I get paid like a pro baseball player, then hey, I’m all for it. Otherwise, I think we need to examine their flimsy analogy a little more closely.

The authors suggest that our medical care is hampered by our lack of data-driven methods. Well, when we examine the American health care system with respect to other countries, we’re actually doing fairly well. The U.S. is a world leader in advancing the cause of evidence-based medicine, and the effects of this trend have reached into every corner of the profession. Thanks to the prolific output of clinical trials, even a lowly medical student can contradict a medical professor if her point is backed with published evidence; this wouldn’t have happened twenty years ago. And I think we’re seeing the positives day-to-day, with more standardization of care and less therapy by doctor fiat. However, what we don’t see as evidence-based medicine becomes more widespread is a decrement in the cost of care.

The problem here is that, with respect to the cost issue, the authors demonstrate their own adherence to a hidebound rhetorical tradition: the logical fallacy of begging the question. They assume as a premise of their argument that evidence-based treatments will be less expensive than those based upon “informed opinion, personal observation, or tradition.” In reality, clinical studies are almost universally designed to demonstrate which therapy is more efficacious, not more economical. In all likelihood, further evidence-based trials will push us toward newer therapies that utilize more health care dollars, as these newer therapies are those that have proliferated in the “profligate” current age of medicine, rather than in earlier, more parsimonious times.

As for the question of quality, evidence-based medicine no doubt has its benefits, but it’s not the panacea the authors would suggest. Certain areas of medicine do not so easily lend themselves to clinical trials. In particular, surgical therapies hinge upon experience and tradition; one would be hard-pressed to create a study evaluating a new, alternative treatment of uncertain efficacy, as neither patients nor hospital research approval boards would be eager to turn away from an established, manifestly effective surgical technique. Suppose your loved one suffered a serious surgical illness; would you want her to receive the tried-and-true, “traditional” treatment strategy, or to be randomized into a study involving an experimental arm with an untested and quite possibly inferior therapy?

We also need to think about the issue of whether we really even want what evidence-based medicine can provide, especially with regard to that spectrum of care that approaches, at its extreme, futility. What if the evidence proves that, in a certain situation, it’s not wise, as illustrated by the data, to try to save your life or that of a loved one? Because, you see, in the author’s baseball analogy, that aging star player whose contract the data-driven team won’t renew corresponds to the aging, debilitated, or otherwise acutely ill person arriving in the emergency department. Should we care for him? Or would it be more cost effective just to let him die, to divert those hundreds of thousands of dollars to some other form of data-driven care rather than spending it on a “hidebound,” heroic effort that could very well save a life, albeit at tremendous expense? This may sound farfetched, but it’s exactly the sort of decision upon which cost-effective care in many industrialized countries is based.

The essence of prudence is sacrifice. I, for one, do not believe that we as a nation are willing to give up our heroic care.

In any case, I applaud the authors for wanting to improve our health care system. What they need to realize, though, is that the problem facing us is complex, and that evidence-based medicine is an important but fractional component of the approach we will have to employ to improve our health care system. To get there, though, we’ll need more than glib analogies and empty rhetoric.

By the way…as for the author’s proposed institute for evidence-based medicine—sounds great! Sign me up. Who, by the way, is writing the check?