The thoughtful introduction is penned by Dr. Fred Goodwin, CMPI board member and Research Professor of Psychiatry at The George Washington University and Director of the Universityâ€™s Center on Neuroscience, Medical Progress, and Society. Dr. Goodwin is the former Director of the National Institute of Mental Health
Here is a taste of Dr. Goodwin's take on the situation.
William Osler, generally regarded as the father of modern medicine wrote "If you listen carefully to the patient they will tell you the diagnosis." Arriving at a diagnosis and appropriate treatment plan has always represented collaboration between individual patients and their personal physician.
But today physicians are increasingly seeing the decisions that they and their individual patient reach about a specific treatment plan second guessed by distant â€œthird partiesâ€ (working for government or insurance bureaucracies) who, of course do not â€“indeed cannot- know the physician or the unique individual circumstances of a particular patient. Lacking any knowledge of the patient or the doctor, these bureaucrats must fall back on general â€œguidelinesâ€ as the basis for approval or rejection of a particular treatment. Having served on guideline development bodies I can tell you that, at best, they represent the kind of â€œlowest common denominatorâ€ conclusions necessary to get the many different opinions represented on a committee to coalesce into a consensus. At worst guidelines represent a deliberate effort to drive down the cost of treatment by emphasizing â€œone size fits allâ€ treatment approaches. While the physician-patient relationship theoretically remains the fulcrum of good medical practice and medical progress, in reality it is rapidly being replaced â€“ on both sides of the Atlantic â€“ by guidelines.
This movement towards guideline-driven medicine to which access to healthcare and physician reimbursement is increasingly linked, is based on the assumption that variations in medical practice are not only wasteful, but also potentially dangerous. Eliminating variations in clinical practice, we are told, will increase quality and save billions that could be poured into covering more uninsured or increasing coverage. The key to standardizing treatments â€“ and outcomes â€“ therefore are guidelines based on a combination of retrospective analysis of randomized clinical trials and the results of large prospective studies that compare the cost and effectiveness of established treatments or drugs in certain disease areas.
I bring a special perspective to this subject because of my professional background. On the one hand I have been a practicing physician for nearly 40 years and during almost all of those 40 years I was medical researcher and policy maker at the National Institute of Mental Health (NIMH). Incidentally my long experience in a part time private practice came about as a consequence of government salaries at the time not being competitive with academia so that a private practice was allowed in order to retain talent.
I was director of NIMH during the health care reform efforts of the first Clinton administration and, as such, I participated in some high level meetings of groups that were part of the effort. It is now well known that the perspective of practicing physicians was not included in this health care reform effort and my involvement was as the governmentâ€™s principal mental health official, not as a clinician. Indeed I doubt that any of the other participants in the meetings I attended even knew that outside of my government job I was a physician in the private practice of a medical specialty.
I present this history so that the reader can understand what I am about to say. The meetings I attended had a surreal â€œAlice in Wonderlandâ€ quality. Here were all of these intelligent, well educated, well intended professionals discussing meta-analyses of controlled clinical trials, outcomes research, etc, etc, and yet it seemed that that none of them really understood what clinical practice was all about â€“ itâ€™s about enormous individual differences even among patients with the same diagnosis, itâ€™s about cross-over trials where the physician uses each individual patient as their own control, trying treatment B when treatment A isnâ€™t working, etc, etc Todayâ€™s advocates for coercive guideline driven medicine (as opposed to guidelines which are advisory to the doctor and the patient) seem to be cut from the same cloth as the people I encountered on those committees in the early 90s, except that now the lure of saving money and increasing the profits of managed care companies provides a new level of passion and intensity to these efforts.
In Europe, doctors are limited by reimbursement patterns and practice guidelines designed to control costs. This trend is growing in the United States. Yet there is no evidence that limiting access based on reviews of clinical literature or large scales trials either improves outcomes or saves money. On the contrary, the outcomes evidence suggests that seeking to elimination variations in practice and prescribing is actually more costly and contributes to morbidity.
The practice guidelines themselves are not the problem, it is how they are applied and for what purpose. Voluntary guidelines provide the intelligent physician with a benchmark from which to mark a patientâ€™s progress or the impact of prevention. I have been involved in the development of practice guidelines for the treatment of mental illness for nearly three decades. It is a given that by the time there are developed, the guidelines themselves are outdated as new clinical insights and biomedical discoveries inform and shape both diagnosis and prescribing. The rigid imposition of guidelines regarding what to prescribe and how to treat insure that doctors cannot tailor treatments to the patient or deliver the best care.
Finally, the emphasis on cost-containment undermines continuity of care. The recognition that someone with mental illness is twice as likely to suffer from heart disease, diabetes or hypertension reveals the interaction of disease pathways which themselves have been show to be highly individualized. The evidence-based medicine movement fails to incorporate such insights. Rather, by emphasizing studies that evaluate the treatment of one aspect of a particular disease in a vacuum, the EBM movement is contributing to fragmentation of care.
Clinical decision-making is becoming increasingly centralized and the domains of economists or physicians who crunch numbers but never practice medicine.
Watch this space for more excerpts from this new and timely publication.