"Evidence-Based" Medicine?

My sister, who is an RN and studying to become a nurse practitioner, recently was required to interview a physician regarding what is known as "evidence-based" medicine. She asked me for perspective.

Here is the question:

The Interview Objective:
To determine individual perspective regarding the significance of research in generating an evidence-based practice for nursing.

Here is my response to her:

Evidence-based medicine is the substitute created by third party payors to replace the traditional boundaries of accepted clinical practice defined by the physician-patient relationship. While the research itself might be useful, the underlying impetus for the research is harmful to the practice of medicine. There will always be outliers among providers, who in a traditional model would likely be marginalized by other providers and by the community itself. With the rise of insurance and government payors and the concomitant weakening of the unique provider-patient relationship dynamic, traditional means to identify substandard providers have been weakened. In general, the American system of health care delivery is excellent, but the brokenness of the reimbursement system will inevitably lead, I believe, to a decline in the quality of care.

Insurance companies are driven not by altruistic motives, but by profit margins, and government by political considerations. While insurors today claim that it's good business to promote wellness and provide thoughtful care, the facts belie their claim. Anecdotal evidence abounds to confirm what is suggested by common sense---that insurance companies prefer to delay and challenge legitimate payments as much as possible. Employers, the traditional conduit for health insurance benefits for the last 40 years, pay insurance companies prospectively on a monthly basis for their employees' health benefits. Meanwhile, in my hypothetical, the insurance company withholds payment for a legitimate service routinely for three to four months. The interest rate "float" generated by this cash flow manipulation must generate millions upon millions of dollars for these companies!

But I digress. The question relates to the significance of the research in generating a particular model of practice. Again, most research is inherently helpful in contributing to the body of knowledge of medicine. Such research has, in my thirteen years of private practice, led to striking improvements in patient care, especially in cardiovascular disease. Examples include the improvement in mortality and morbidity from tighter blood pressure control in hypertensive patients or glycemic control in diabetics. We are currently in the midst of a dramatic increase in the use of statin drugs due to overwhelming evidence of their benefit. All of these treatment trends are beneficial to patients.

Unfortunately, clinical patient encounters resist the precision inherent in the scientific method. This makes quantitative assessment of patient care very difficult, and current methodology is very primitive. It's my belief that an excellent clinician might have, on the basis of a number of unmeasurable variables, poor results in such analyses. Patients don't come to the doctor with Problem X, Y, or Z. They come in as themselves, indivisible, and the art of the clinical encounter is in managing that session to the benefit of the patient. Treatment based on evidence is desirable but incomplete unless it is modified to a patient's particular circumstance. I recently put a patient on an angiotensin-receptor blocker for his newly-diagnosed hypertension, and his insuror resisted paying for the medicine. Evidence-based guidelines would suggest that I use a different and less expensive drug. But I know that this patient is resistant in coming to the doctor in the first place, would be non-compliant with any medicine with even mild side effects or an inconvenient dosing schedule, and his sister and mother developed a cough when placed on ACE inhibitors. His insurance company and the evidence-based reviewers don't care about these things. This is a trivial example but the first to come to mind, and it illustrates in a small way the factors which are encompassed in an encounter.

A provider who bases her practice on evidence-based medicine is an automaton who would miss critical nuances. On the other hand, a provider who incorporates evidence-based practices into a framework of basic science education, clinical experience and compassion will provide superior care. Payors and regulators, however, will not necessarily be impressed. This is one of the major sources of tension in American medicine today. At their core, evidence-based clinical guidelines are a tool for clinicians, but are not an end unto themselves.

End of my response.

I will soon post more on what I believe is a fundamental problem with America's health care reimbursement system. Notice that I intentionally specified "reimbursement." It may be self-serving, but my perspective is my perspective, and I think America's health care system is excellent. However, as I noted above, the health care system is imperiled by a broken payment system.

A note about last night's Republican Presidential Debate. Mike Huckabee again distinguished himself among a host of men who will say anything to be elected President. When I heard his response to a question about evolution, I wanted to (and did) stand up and applaud. Many folks have not taken the time to become familiar with Huckabee, but I urge you to take a look. He is an impressive guy. He has given I think objectively the best performance through all three GOP debates.