Friday, December 6, 2013

When Evidence Based Medicine Was Best for Patients' Health

I was privileged to have been trained and worked in the imperfect Halcean days of UK medicine. It was far from perfect but it was rapidly accelerating in that direction, perhaps because it was led by senior doctors who had lived at the top of their vocation based entirely on doing their best for the patients and their health.

It was these doctors that invented and designed Evidence Based Medicine. They did so selflessly for their patients' long term health.

That original EBM, created by doctors for patient health, has saved lives immeasureable. It is Evidence Based Medicine that brought the importance of lifestyle into full focus.

One of the most important advances was to test old wives' tales that had never been tested. Bedrest and exercise avoidance were found to be major disablers and killers rather than helping the body to recuperate and improving prognosis. Unproven assumptions, like hospital is the best place to be when you are even the tiniest bit ill and the safest place to be if you are not particularly ill just in case you do get ill, were tested and catgorically disproven.

Specialist care must be the best care!

No, not unless you really need specialist care. A well trained primary care doctor provides safer care for the generally well population. They are used to caring for that well population and do so with common sense. The mind of the expert is coloured by their world and experience. Show them a well person and they treat them as a severe case. They overinvestigate and overtreat generally well patients.

One of the great advances of Evidence Based Medicine was to bring objectivity and thought to every treatment decision. It was EBM that brought the culture of intensive evaluation of side effects of investigation and overmedication. The risk benefit decisions became more difficult, more personal and a risk benefit analysis had to seriously be made before doing anything.

X-rays and CTs cause leukaemia and cancer and were only to be used if they changed management. More invasive procedures had significant immediate mortality. Even the safety of newer radiological techniques such as MRI and ultrasound was questioned in light of the terrifying number of decades and patients investigated with X-rays before those risks became clear.

Then there were the indirect risks of all investigations, even the most innocuous such as a blood test. Their risk lay in the false positives and negatives. By their definition of 'normal', most blood tests automatically have a 5% false positive rate. In standard batch testing used for a simple blood count and checking electrolytes, it is statistically abnormal to have all normal results. MRIs have an incredibly high false positive rate for detecting musculoskeletal conditions that do not exist clinically and hence do not need treating surgically. And abnormal results in normal people become justifications for more invasive tests and unnecessary treatment.

Evidence Based Medicine returned the power to the clinician and their acumen at a time when they were under threat from the wonders of medical technology. The best diagnosis was the clinical diagnosis, aided where necessary and appropriate by the machines.

It also provided excellent sources of multidisciplinary rather than peer reviewed medicine, such as Cochrane and NICE, a higher standard in the life and death world of health and especially important because study design and statistics are so difficult. They are difficult. This is a higher standard than typical academic science. Even major scientific journals are not good at it as specialists in the field often lack independent objectivity and statistical skills. Grass root doctors cannot be expected to be able to constructively criticise.

So guidelines were created to help doctors in light of the massive amount of clinical papers and journals available. They were assessed by the highest experts in the field. They were guidelines of first line treatment for average, uncomplicated cases and vague guidance in more complex cases. Exceptions for those exceptional cases were made according to clinical acumen in the individual case. And if the first line did not work, it was up to the clinician.

These guidelines did improve patient health. They gave patients an assured standard of practice wherever they went. And doctors were no in conflict with one another's opinions.

And higher medical standards have forced pharmaceutical companies into higher standards in their studies. Many old drugs were re-evaluated. Several failed. Several had been accepted on theory and failed in real outcome in real life. Several had not had their side-effects fully evaluated and were prescribed on hope rather than evidence.

The monopoly of surgery and pharmacy was broken. The previous medical culture, Theoretically Based Medicine, was biased and rejected other therapies because science did not find the theories behind them scientific enough despite the evidence in the real world. This did not just include acupuncture or relaxation therapies. It is still difficult to see 'scientific' theories for physiotherapy and psychology.

It was simple. The therapy that had the best benefit/risk profile was the best whether science or doctors liked it or not. That was irrelevant. The best therapy for the patients' health should be used or recommended. Particularly in minor and self-limiting illness, where the benefit of any treatment is marginal in long term outcomes, often pharmacy and surgery lost out.

So this was the dream. The original EMB was to improve health. It was a moral crusade for an ethical medical profession. It was a selfless crusade that was not always in their interests in the short term. However, it was to answer any criticisms about the medical profession and preserve their honour, reputation and public trust.

It was also teamed with other practices to improve doctors' performance and improve standards, such as continuing medical education, audit and a 'no blame' culture of openly examining every negative event in multidisciplinary groups as a learning experience to all in order that misjudgements were not repeated, even other people's misjudgements.

All this was organised and instituted by highly ethical doctors for the good of their patients' health.

A sign of those ethics at the time was that 50% of primary care agreed to manage their own budgets. They would make savings by curing over-medicalisation and taking on the responsibility of less investigation, less hospital referal and less hospitalisation. They were taking on responsibility for the high level work that hospitals had previously been doing. They would not be delegating that work.

They would receive no extra pay for more hours and more responsibility. What they would receive was extra benefits for their patients from the savings they made through the highest levels of practice. They could have visiting specialists or in house physiotherapy and psychology to cut down on hospital visits and waiting times. They could even have relaxation classes or Thai Chi teachers brought in as exercise for the elderly to keep them fit and healthy.

50% or more of UK primary care took this offer of much more work and much more difficult work for the same pay for the good of their patients.

It was not about cost cutting or rationing. It was an ethical quest for gold standards in patient health. It just happened to cut costs coincidentally by reducing hospital stays and drug/investigation costs.

Evidence Based Medicine trims the fat to make healthcare lean, fit and of the highest quality. The problem is that the government wanted its pound of flesh too and to cut healthcare to the bone. That is when it put in administrators, management consultants and beancounters who did not understand healthcare or its noble culture to replace doctors and other healthcare professionals that did. 

They succeeded. They cut costs and corners in the name of efficiency statistics. They devasted the noble ethical culture by teaching doctors to think like managers, even speak like them. They taught them to think like penny pinching beancounters.

This created another form of 'Evidence Based Medicine' that was cost centred not health focused. It was not about health outcomes any more. It became about making care average, not excellent. It was for the benefit of the government and the administrators, not the patients.

It is when guidelines became protocols and clinicians were not allowed to make exceptions for exceptional cases. They were not allowed to think for themselves. They had to do the cheapest thing in the short term regardless of the long term health costs. Medicine was cheapened.

The nobility of the medical profession was cheapened and tarnished.

And that just about sums up the flavour of Evidence Based Medicine that is being imposed on the American medical profession by the insurers. It is not driven internally by ethical health professionals to improve health. It is imposed externally by administrators and beancounters with no medical experience and without medical ethics.

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