Wednesday, February 9, 2011

Evidence and profit: An unhealthy alliance

My JAMA Commentary came out this week, and I am getting e-mail about it. It seems to have resonated with many docs who feel that the research enterprise is broken and its output fails them at the office. But what I want to do is tie a few ideas together, ideas that I have been exploring on this blog and elsewhere, ideas that may hold the key to our devastating healthcare safety problem.

The last four decades can be viewed as a nexus between the growth of evidence-based medicine (EBM) on the one hand, and the unbridled proliferation of the biopharmaceutical industry and its technologies. The result has been rapid development, maximization of profit, and a juggernaut of poorly thought-out and completely uncoordinated research geared initially at regulatory approval and subsequently to market growth. It is not that the clinical research has been of poor quality, no. It is that our research tools are primitive and allow us to see only slivers of reality. And these slivers are prone to many of our cognitive biases to boot. So, the drive to produce evidence and the drive to grow business colluded to bring us to where we are today: inundated with evidence of unclear validity, unbalanced with regard to where the biggest difference to public health can be made. Yet we are constantly poked and prodded by the eager bureaucracy to do better at implementing this evidence, while the system continues to perform in a devastatingly suboptimal fashion, causing more deaths every year than strokes.

A byproduct of this technological and financial race has been the rapid escalation of healthcare spending, with the consequent drive to contain it. The containment measures have, of course, had the "unintended consequence" of increased patient volume for providers and of the incredible shrinking appointment, all just to make a living. The end-result for clinicians and patients is the relentless pressure of time and the straight jacket of "evidence-based" interventions in the name of quality improvement. And in this mad race against the clock and demoralization, very few have had the opportunity to think rationally and holistically about the root causes of our status quo. The reality is that we are now madly spinning our wheels at the margins, getting bogged down in infinitesimal details and losing the forest for the trees (pardon all of the metaphor mixing). Our evidence-based quality improvement efforts, while commendable, are like trying to plug holes in a ship's hull with bandainds: costly and overall making little if any difference.

But if we step back and stop squinting, we can see the big picture: stagnated and outdated research enterprise still rewarding spending over substance, embattled clinicians trying to stay afloat, and a $2.5 trillion healthcare gorilla feeding the economy at the expense of human lives. Will technology fix this mess? Not by itself, no. Will more "evidence" be the answer? No, not if we continue to generate it as usual. Is throwing more money at the HHS the solution? I doubt it. A radical change of course is in order. Take profit out of evidence generation, or at least blunt its influence (this will reduce the clutter of marginal, hair-splitting technologies occupying clinicians' collective consciousness), develop new tools for better patient care rather than for maximizing the bottom line, give clinicians more time to think about their patients' needs rather than about how to maintain enough income to pay for the overhead, these are some of the obvious yet challenging solutions to the current crisis. Challenging because there needs to be political will to implement them. And because we are currently so invested in the path we are on that it is difficult and perhaps impossible to stray without losing face. But what is the alternative?


  1. MZ, another insightful commentary on our downward spiral in which we accidentally collude with the medical industrial complex (MIC) to accidentally bankrupt America and Americans. As a Family Physician at the bottom of the funnel, I see no way out of the muck. The "guideline-itis" driven by the research to which you refer is slowly crushing the humanity of family doctors who wish more to connect to the patients reality than that of shareholders of the MIC. The clinical encounter in FM doesn't really start until the pt-dr dyad gets to "the fourth paragraph" of the pts story. Budget crunches cause many drs to stop in the 1st paragraph and just give mechanical responses to pt (unexpressed) need.
    Your voice of truth about uncertainty, safety, public health, etc. may go viral enough to help create the next reality (I hope) but I'm worried/stuck in the muck at the bottom. (?no where to go but up?). Thanks- BLOG ON!

  2. Dr. S, it breaks my heart that dedicated physicians like you are that demoralized...

  3. Dr. Zilberberg,

    I just read this week's JAMA and I enjoyed your commentary. I am a family physician (and former student of yours) and remain optimistic about the future of primary care medicine. I agree with you that change is needed and I am intrigued with your heterogeneous treatment effect discussion. You also note that "...progress will be better understanding of genetics." One vision of the future is an electronic medical record system with the patient's genetic code stored on the server which will allow the physician to provide personalized medical care. For example, a physician will be able to avoid prescribing a statin to a patient who is genetically predisposed to myopathy. Time will tell how genetic research will play out.

    Paul Kruszka, MD

  4. Hi, Paul, great to see you here! Hope you are doing well.

    Yes, genetics holds such hope, but it is unclear when we will reap its full rewards. For over a decade there has been money thrown at genome-wide associations studies, which have yielded a lot of information, but not much knowledge that is usable so far. There is a move afoot to go in the direction of genome-wide interaction studies next. We will see what those yield. For the moment, we will have to be content with our usual clinical research tools, but learn to use them a lot better, more effectively and efficiently.

    Thanks for your comment. Hope to see you here again soon.