Unfortunately as an alternative provider, the medical evidence used to ration care still almost exclusively excludes the kind of care I do, meaning many patients are unable to benefit from it.

The article is a little long, but worth reading.  Find it here.

What are your thoughts?  Is rationing an unfortunate necessity?  Share them with us in the comments section below.

Part III of this series

In part I of this series, I explained what I believe evidence based medicine (EBM) should be:  the equal use of clinical experience and external evidence to make the best decisions about the care of patients.  In this interpretation of EBM both clinical experience and external evidence are important and necessary.

Clinical Experience <—-> External Evidence

Unfortunately this interpretation is rarely used in current discussions of EBM.  Instead we find this version of EBM widely promoted.

1.  Randomized, controlled studies

2.  Other studies

3.  Clinical experience & “consensus” opinion

Under this interpretation, the value of evidence is now ranked.   Double blind, placebo controlled studies are given the highest value, followed by a variety of other studies, and lastly clinical experience and consensus views from committees, associations, and experts.  Instead of external evidence and clinical experience being given equal weight we now find that clinical experience is considered the least valid (and valued) form of evidence.

This form of EBM is often used to disparage and discredit alternative or non-mainstream therapies with the refrain, “there’s no / not enough evidence” because the only evidence considered worthwhile is that produced from studies, and especially from double blind, placebo controlled studies.  The reports of hundreds or thousands of doctors and hundreds of thousands or millions of patients are brushed aside with the comment “anecdotal” as if that means they have no value.

To run a well conducted scientific studies, especially double blind placebo controlled studies, requires  scientists to be hired, the study designed, subjects recruited, screened, and selected, the trial run for weeks, months, or years (in some cases), the data collected, analyzed and then published.  All of this isn’t free and in fact costs a tremendous amount of money.

The government does sponsor some studies, but the current budget allocated for studying alternative therapies is pathetically small.  The majority of studies are funded by private companies, and in a capitalistic society the goal of business is to make money.  Studies funded by private companies are not done to prove whether a therapy is effective or not, but ultimately to prove that their therapy (being studied) is effective so that the results can be used to promote that therapy, and make money.

For example, a pharmaceutical company comes up with a drug they believe might have potential, they patent it which gives them exclusive rights to sell it for a period of time.  This ensures that if the drug is shown to be useful they will be the only ones who can sell it and therefore they will be able to make a lot of money with it.  The company will then fund scientific trials to prove that it is effective and bring it to market.

In contrast, something like vitamin C is cheap and widely available.  It is a natural substance and so cannot be patented.  If a company paid for a study on vitamin C and found it beneficial, anyone selling vitamin C could use the study to promote their brand of vitamin C.  The company that spent the money to have the study done would not have any advantage because they cannot patent and hold exclusive rights to vitamin C.  In fact the sponsoring company would be at a disadvantage because they spent the money to have the study done, while competitors could use the results of the study for free.

Pharmaceutical companies run the majority of trials on medical therapies, and because they cannot own natural therapies most natural therapies are not studied.  Further, as many natural substances may be replacements or alternatives for drugs, pharmaceutical companies have a further disincentive to conduct trials on natural substances.  The only studies they would have interest in running are those that prove that natural substances don’t work or are inferior to their products.

Therefore as alternative practitioners we find that the majority of our therapies are not studied in scientific trials, because there is no profit in doing so.  Most supplement companies, alternative medical societies, associations, and schools are small and don’t have the millions of dollars needed to run the studies to “prove” that the therapies work.  Evidence from practitioners and patients is discounted as anecdotal and therefore “worthless”.

Under this version of EBM, the conventional community claims there is no evidence to support the use of alternative therapies.  However, if we turn this same standard upon the conventional community, we find they have little evidence to support many of the practices and therapies they use.  By some estimates, up to 80% of conventional practice do not have sufficient studies behind them to justify their use under this version of EBM.  Most MDs rely on evidence presented in scientific journals, what they are told by pharmaceutical representatives about medications, their own clinical experience and the consensus opinion of their colleagues and medical associations to provide evidence for the use of their practices and therapies.  The majority of this evidence is considered lowest tier evidence under this version of EBM.

It is my belief that this version of EBM sets unrealistic and non-usefully high standards for what can qualify as evidence to justify therapies and practice, and by doing so denies patients effective care.  In part III of this series I will lay out the form of EBM that I use in my practice and how I feel it best serves my patients.

What are your thoughts and opinions on EBM?  We’d love to hear them.  Feel free to share them below.

Part III here

Evidence based medicine (EBM) has emerged as one of the key concepts being debated in leading medical journals, doctors offices and conventions, insurance boardrooms, and government agencies  as a major piece of  the effort to reduce costs and improve outcomes in medicine.  In this series I’ll be explaining what evidence based medicine should be (part I), is (part II), and how I use it in my practice (part III).

The definition of evidence based medicine I believe makes the most sense comes from this paper.  BMJ 1996;312:71-72 (13 January) Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS (1996). “Evidence based medicine: what it is and what it isn’t”. Excerpts from the paper will be in italics.

“Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

The intention behind evidence based medicine is a good one.  As doctors we want to carefully and consciously use the best evidence to select therapies that are helpful to patients, and avoid those which are harmful or useless.  As the article says:

“[The purpose of evidence based medicine is to] invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious [effective], and safer.”

Whatever gives us the best results is what we want to use for the good of our patients.  But, how do we decide what is the best evidence?

“The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

We combine our clinical experience as doctors (personal, subjective evidence) with the best evidence from external sources (impersonal, objective experience).   In contrast to what we will see in part II of this series, we see that evidence based medicine combines the clinical experience of the doctor with external sources, such as the scientific literature.

The article continues: “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.”

In this view of evidence based medicine, which I subscribe to, both clinical experience and the scientific literature are equally important.  One without the other is insufficient and leads to poor practice and outcomes.  Clinical experience without external evidence is narrowly focused and becomes quickly out of date, and the external evidence without clinical experience attempts to fit a “one size fits all” solution to individuals, which typically works very poorly.

In part II, we’ll move away from what EBM should be, to what it most often is.

What are your thoughts and opinions on EBM?  We’d love to hear them.  Feel free to share them below.

I recently watched two Bill Moyers webisodes, one on the insurance companies, and one on the pharmaceutical companies.  They’re around 20-30 minutes each and well worth watching.

Bottom line: Insurance and pharmaceutical companies are businesses just like any other American capitalistic business.  That means their first, most important, and only goal is maximizing their bottom line.  If they don’t, Wall Street punishes them and their stocks plummet in value.  In that regard they are no different from Wal-Mart or Apple computers.  The difference is  that when other companies maximize their profits, they lay off people, or deliver a cheaper, inferior product.  When the insurance and pharmaceutical companies cut costs and increase profits they drop coverage, raise policy rates, deny care, and increase the cost of medications.  This, indirectly, results in the suffering and death or real, live people.  Should these industries play by the same rules as other non-healthcare businesses?

But it goes beyond that.  Removing people from policies or increasing rates are legal and legitimate (at least sometimes).  But as this story illustrates, insurance companies are more than willing to use quasi-legal and ethically scum-bag behavior to further their bottom lines.  And recission, where the insurance companies look for any excuse (no matter how trivial) they can find to deny care, is equally vile behavior.  And it gets worse.  Both industries routinely buy off politicians (the pharmaceutical industry has two lobbyists for every member of Congress) to prevent legislation that would bring these practices under control… and reduce their profits.  And more…

The pharmaceutical companies:

1. Engage in deceptive direct to consumer advertising that down plays side effects and shows images of people frolicking through fields and beaches and other idyllic scenes (if you take their drug).  These ads also serve to medicalize normal life events.  Where before it was a result of aging or other normal circumstances, it’s now an actual disease, which of course requires treatment with a drug.
2. Turn the scientific literature into little more than propaganda.  Perhaps their worst offense.  Many of us believe in scientific studies, that it helps us understand the truth.  Sadly this is not the case.  It’s been clearly shown that they…
   1. Rig scientific trials.  Design the studies for scientists so the outcome they desire is guaranteed.
   2. Ghost write trials (this is most often done by an ad agency, not a scientist) so that the studies say what they want them to say.  This has gone as far as completely making up the data used in studies.
   3. Repress studies that disagree with the point that they are trying to make.  Studies are rejected by journals (can’t get published).  Studies fail to get any attention in the media.  Scientists are told they won’t receive any funding for future studies, or that they will lose their jobs, if they study the “wrong” thing or have “wrong” conclusions.
   4. Create inaccurate media frenzy.  Which studies make the headlines?  Most often, those with pharmaceutical sponsors.  Pharmaceutical companies buy a lot of advertising in media.  Publishing an article with the “wrong” conclusion can cost TV stations, radio, and newspapers major advertising revenue, so it often doesn’t get published.   What does get published is too often ghost-written by ad agencies, not reporters.
   5. Buy experts.  Try to find an expert in a field and chances are almost certain they have been “bought” by a pharmaceutical company.  Whether it’s research money, gifts, vacations, or just plain money, many “experts” make a great deal of their livelihood by sticking to the corporate line and being generously rewarded.
3. Buy doctors.  Like the experts most doctors are relentlessly chased by drug reps who are beautiful (many come from the ranks of cheerleaders and models), young, and friendly, who flatter and pay attention.  Who provide gifts (from pens and notepads, to free dinners, free events, free vacations), and samples.  The reps use computer programs to monitor the prescribing habits of doctors.  Doctors who prescribe more of their drugs receive greater rewards, doctors who prescribe less get more pressure.  Most doctors genuinely believe that their decisions are their own, but studies have shown this is far from the truth.  These salesmen and women profoundly impact the medical decisions that doctors are making.

Both industries have taken strong notice of the tactics used by the tobacco companies, and use them to aggressively maximize their bottom lines, even as they cause death and suffering.

If we’re honest, we have to say that these two industries are probably no worse than others.  We’ve seen the lows that the financial industry went to, in terms of short-term profit, creating trillions in debt and plunging the world into a recession.  The capitalist system, as it applies to health, is filled with incentives to make money and disincentives to provide good care.  Should we expect any better from the pharmaceutical or insurance companies?

Watch Bill Moyers interview with Wendell Potter on insurance companies here.

Watch Bill Moyers interview with Melody Petersen on pharmaceutical companies here.

What are your thoughts?  We’d love to hear them.  Please post your comments below.

This story was passed on to me, and left me disturbed and angry.   The problem with insurance and health care is not just with the uninsured, or the under-insured, but is very real even for those with the best insurance policies.

The idea behind insurance is, of course, that we pay a modest (hopefully) amount of money into the system when we are well so that if/when we become sick we are able to draw on the insurance to cover our expenses.  What we’re finding out, as this story suggests is that insurance companies are taking our money when we are well, only to find a way, either directly or indirectly, to cancel our policies or find a way not to pay.  To me this is a breech of contract, if not legally, than ethically and the companies, their executives, shareholders, and employees should be ashamed.  That money, that extra profit, comes at the cost of inflicting death and suffering on people who in good faith have been paying into the system.

Bottom line: Get a serious disease, like cancer, and your insurance company will massively increase your rates, effectively bouncing you out of the system.  A diagnosis of cancer, or other similar disease, means your insurance company will send you or your spouse’s employer (if you care covered through them) a rate increase of $1,000,000 per year.  What this means is that small business (who can’t afford the increase) are forced to either drop insurance coverage for all of their employees, get rid of you, or go out of business.  Large businesses that can technically absorb the cost simply find a way to get rid of you.  So you become uninsured and unemployable (by any company that offers health insurance because, when you come on their plan with that diagnosis their rates jump up $1,000,000 per year).  The only way out of this vicious cycle in our society is to go broke and get on Medicare (if you’re old enough) or Medicaid (if you’re not).

Disgusting, deplorable, and wrong!  Read the post, get angry, and let’s do something to change the system.  Whether you believe in public insurance, private insurance, single payer, or something else, one thing is clear, the system, the way it is, cannot continue!

Read the story here.

What are your thoughts?  What do you think we should do to fix this?  We’d love to hear from you.  Please feel welcome to post your comments below.

I recently saw a PBS special called Sick around the World.  The basic idea of the show was to look around the world at other modern democracies and see how they have implemented universal coverage.  By learning from them perhaps we can find solutions to our own problems.  Reporter T.R. Reid traveled to five countries: Great Britain, Japan, Germany, Taiwan, and Switzerland to understand their universal health coverage.

Bottom line: If we want to provide universal coverage to our population here in the US, there are the lessons taught to us by other modern democracies doing it.

1. It is possible to create universal coverage using private insurance companies, private doctors, and private hospitals.  However, health care cannot be left entirely to the free market and must be regulated.
2. Insurance companies must be forced to accept everyone; no exclusions, no pre-existing conditions, no dropping coverage, etc.
3. Insurance companies should not be able to make a profit on basic care.  Insurance companies in countries like Germany and Switzerland are non-profits.
4. Everyone must be forced to buy health insurance; the government pays for policies for the poor
5. Doctors, hospitals, pharmaceutical companies and equipment manufacturers must accept fixed prices for their goods and services.  In all 5 countries visited doctors earned less than they do in the United States.  This was offset by the fact that they graduated without medical school debt (often around $200,000 in the US) and their malpractice insurance was 1/10^th of what it is in the United States.

The special is a little less than an hour, available free on the Internet and well worth your time.  While the issue is massive and complicated, if we believe health care is a right and we see that other modern democracies are providing it, aren’t we obligated to as well?

Watch the show here.

What are your thoughts?  Is health care a right or a privilege?  We’d love to hear from you, please post your comments below.