November 14, 2007
“Evidence Based Medicine” was the original dream of an accountant in England named Archie Cochrane. He decided that if all of the medical articles in the world could be synthesized into pure knowledge – and weighted toward levels of certainty – then out would come a central logic of what to do in most or all situations. And so the Cochrane Collection was created and is ongoing on the Internet. To itself it is fairly pure and unbiased – like a glacier on the top of the mountain.
England was the first to try to manipulate the collection to the government’s supposed benefit and decided that at York there would be clinical testing or validation of the Cochrane evidence. They immediately picked out those topics where they might save money – so that less care could be given if possible to so prove. Pure knowledge is budget neutral – creating more care for some problems and less for others. But to no one’s surprise the government paid for and got back what it wanted – minimalist care.
The actual term “Evidenced Based Medicine” or EBM was dreamed up in the Family Practice Department of McGill University. They have conceded that what they really wanted to create is “Expert Absent Medicine.” Clearly it would be cheaper to punch up the computer than asking real experts. Instead, the practicing physician was to become dependent on reviews of reviews. The physician – burdened by medical school to be free thinking and challenging to the changing world of science – could now simply leave the thinking to others. In fact, there is even a bizarre approach to give every symptom a diagnostic weight so in combination the physician analysis is no longer needed.
The rivalry between narrative medicine (the careful interview of the patient and building up of diagnostic clues) is still championed by Harrison’s Textbook of Medicine. The rival Cecil and Loebe has allowed its diagnostic chapter to be written in the EBM style of weighing symptoms computer style. Harrison acknowledges the advances of evidence but still finds the most complex of medical skills – a good interview – to be best governed by and then taught by experts. In terms of our glacier, we are starting to work our way down to the forest of animals and their discharges into the mountain streams.
HMOs decided that EBV if yoked to their goals of “the less we do the more money we make” (Kaiser CEO to Nixon summary in SICKO), then the public would have no legal defense against being victimized by disease. It goes along with illness being life style created so being sick is about the same as being bad. Thriving is something joggers do each morning, not really a promise of a prepaid health plan. Experts – on the Kaiser Website – were once pictured as old men with simply the halos of balding hair. After I pointed that out, the Website morphed.
To see the “malignant heart” approach used by HMOs in blocking care, one needs to hold side by side the original evidence against the “evidence” within the secret Guidelines and Pathways of the HMO. The American Diabetes Association, for example, states that all couch potato types need to be tested for diabetes rather than waiting until a few show up suddenly needing dialysis. Kaiser carefully changed this recommendation so that such folks would not be tested in a chart that almost matches but has been fudged toward less care. At the same time the for profit Permanente physicians carefully invested in dialysis ventures.
In such a case, all risk is shifted to patients. Disease become the internal ovens that cook from within. In fact, the perfect art of HMO EBM is to catch diseases right at the point of dialysis or hospice – as new federal money suddenly pours in. If cancer is diagnosed just late enough, it can be declared hopeless just as it is found. legally, the HMO’s care cannot be challenged if the chance of cure drops below 50%. And the medical records are spoiled anyway by Risk Management – so who cares?
Perhaps the easiest example that one can follow of the perversion of EBM – somewhere near the polluted delta where swimming is not allowed – is that which Kaiser produced by “partnering” with the Communicable Disease Center for anthrax diagnosis. Kaiser stated that a low oxygen level was a good screen for anthrax. The CDC explained that Anthrax – though inhaled – often bypasses the lungs on the way to mediastinal involvement and shock; low oxygen would only be a too late sign. Kaiser intent in its release of a protocol was to cover up missing an anthrax patient and actually set up to NOT catch the next case.
Yet, for Kaiser – on their Permanente Medicine Map – the only way to the “Sustainable Future” for the fleet of Permanente (pictured as a group of ships) is through the straights of EBM. This is the pathway for each partner physician to end up with a millionaire’s pension, e.g. $15,000 a month plus social security. But the partners can never tell the above tale because the pension is all potentially gone if the same physicians do not support the HMO and its expansion (yes – in writing). This is the great “gag” clause. Like all good ideas that get translated into profit, evidence based medicine is now so contaminated with dysinformation that it is dangerous. With EBM nurses will hold out in HMOs to be practitioners – though only RNs with no diagnostic training – and withhold antibiotics from all but those yelling for them. And since it is “evidence,” it does not matter if it is given out by the least qualified. The patient history – 90% of diagnosis – is tossed out the window as time consuming. After all patients are simply “the worried well” using up health dollars instead of eating broccoli. Judges will find themselves weighing competing “evidence” journals – medical experts no longer needed in court.
I sound like the near extinct physician eagle flying over the canyons of the past. But then I am comforted to know that ER physicians in general have remained skeptical about this new panacea of information. In fact, the lead ER journal noted that by the time “evidence” has gone from the source to the frontline it has passed through 11 prisms of value judgment. The “retrospectoscope” is not as clear as we had hoped.
When I get sick, I will look for an expert. That expert will be able to quote all the current lead articles but will also bring to bear experience. And, yes, his or her white coat will really stand for the oath of patient loyalty. For that moment in time, I will be the north star around which the medical world revolves. I will have a champion willing to take on the dragon of disease. I will not be a stepping stone to the expert’s retirement plan. Sorry, Archie. You had a good idea. We need to perfect the collection and selection of knowledge. But there are white coats and green coats. Until it becomes profitable to give superior care, “evidence” is often just the pathway to doing nothing. Chuck Phillips, MD, FACEP