Let’s call it like it is, the canard of evidence-based medicine is one-size-fits-all medicine. At its core it is cost-based rather than patient-based.
According to Greg Scandlen of the Heartland Institute, the concept of evidence-based medicine is founded on a few key ideas:
* First is that there is too much variation in medical practice, and variation is a bad thing. We should know what to do and do it in all cases, the idea goes. Medicine should be standardized around what is known to work.
(Of course this also presupposes that all people respond precisely the same way to all medicines. Sure. And if you believe that one, let me introduce you to my pet rabbit Harvey.)
As Mark McClellan said, “Looking at a gigantic uniform solution for everything is never going to work.” (JD Kleinke, Health Affairs, May/June 2004; 23(3): 177-185.)
* Next, there is only one way to determine what works and what doesn’t — using randomized, double-blind studies and measuring the effects on large populations to develop guidelines and practice protocols.
(I suppose that, after all, without our traditions our lives would be as shaky as … a fiddler on the roof!)
* Third, physicians who fail to follow those guidelines should be punished.
Scandlen opines, “Under this scenario, the only room for debate is around the severity of the punishment. People have argued that noncompliant physicians should be paid less, have higher premiums for malpractice coverage, lose their hospital privileges, be kicked out of insurance networks, and/or have their medical licenses revoked. I haven’t yet heard anyone argue that noncompliant doctors should be thrown in jail, but it is only a matter of time.”
Indeed. Perhaps this will encourage Consumer Reports to move beyond offering “best buys” on medications for Alzheimer’s Disease (see blog “Crash-Test Dummy Medicine,” 3/6/06) to legal advice on how to sue physicians for practicing patient-based medicine.
(Sadly, I’ll bet the folks at Consumer Reports don’t find this concept so outrageous.)
One-size-fits-all medicine may provide transitory savings in the short term, but the same patient who takes the cheapest available statin today may very well be the patient costing you — the taxpayer — the policymaker — the thought-leader — the sister — the spouse — big bucks when that patient (otherwise known as a “person”) ends up in the hospital because of improperly treated CVD.
And make no mistake, by “improperly treated” I mean treated with the least expensive rather than the most effective medication.
The reprecussions of short-term thinking vs long-term results, of cost-based over patient-based, of one-size-fits-all medicine, is pernicious to both the public purse and the public health.