Friday, November 20, 2009

Evidenced based medicine

Evidenced based medicine is the terminology physicians use when we talk about medical practice which is based on studies large enough to have statistical significance. If you are not a physician it is difficult to understand how much of medical practice is based on dogma. This makes one of the best things about medicine one of the worst things about medicine, a patient's trust in their own individual physician.

Several years ago when remodeling our house the electrician gave us an estimate based on the plans which were drawn for the remodeling project. The demolition crew came and went. The electrician returned. He carefully went through the wiring again, ask to meet with me and my husband, and gave us the bad news. Wiring uncovered in the tear out was not code. It had probably been done by the previous owner and was in fact, a fire hazard. If we wanted him to do the wiring he would have to increase his bid by 20%.

My husband had a fit and was ready to fire the guy on the spot. I one the other hand reasoned the following: This man has a license. The city is going to inspect his work. We don't want to have a fire. I am going to trust him. I told my husband if he was that upset by the price increase we would get a second opinion from another licensed electrician. We went ahead, finished the remodeling project and twenty-five years later, everything in that kitchen is working fine.

Standing there with the electrician that day, I remember thinking, "I don't know electricity. I know medicine. I can trust this guy or I can get someone else I trust but I am never going to know electricity. Someone, hopefully an electrician, is going to give me the correct information."
(Also understand we did not yet own a personal computer nor was the Internet a household word so maybe my position was made a bit simpler by these two facts.)

Ever since that incident, I have hoped my patients trust me as much as I trusted that electrician. Over the years my patients have brought me newspaper articles, magazine clippings, and yes, websites to view. I have been given books, DVDs and tapes from the lay press. One patient offered to pay me to watch a thirty minute video about natural hormonal replacement therapy in hopes I would write the prescriptions she desired.

Through it all, I have tried to stay abreast of both what The New York Times and The New England Journal print along with Cosmopolitan, Glamour, and O. In these later years, I have even given in to watching television advertising by the pharmaceutical industry to try and hear what my patients seem to hear and believe will make their lives better.

So you can imagine I have been all eyes and ears these past several days as the new recommendations for breast and cervical cancer screening are released. I sat down this morning to write Diane Ream and the editor of my local paper but instead chose to put my thoughts down here.

First, both the Preventative Services Task Force and the American College of Obstetricians and Gynecologist are made up of excellent physicians much more knowledgeable than I about statistical analysis and evidenced based medicine. It is true, many of them have not spent their lives as I have holding patients hands and advising individuals on health care decisions. But these women and men did look at the evidence. They did not sit around as we practioners often do speaking only of their individual experiences. That is the kind of stuff which led to the dogma that every woman should begin hormonal therapy at menopause.

Second, I have two patients I can name, one now dead, which were low risk for breast cancer and normal routine screening mammograms DELAYED the diagnosis of their breast cancer. At the risk of being long, I will tell you the story of one of them.

At forty Barbara did what most obedient, health conscience, American women do. She had her baseline screening mammogram. It was totally normal. Three months later she felt a lump. She surmised it was normal since her mammogram had been. Just a function of the normal monthly ebb and flow of her hormones, she told me later. She forgot about it. Until nine months later when I felt it on her yearly examination. Not only could I feel that lump but I could feel a lump under her arm, the early metastasis of her disease. A disease that did not show up on her mammogram even on retrospective inspection by multiple radiologists (the case has been through several attorneys and expert witnesses.) She delayed seeking care because of a routine mammogram which was negative. Today, despite aggressive treatment, she is dead of her disease. I often wonder, what if she would have come in when she first felt the lump, which was solid and would have been biopsied regardless of mammogram findings, would she be alive today? She had no family history. She was in a low risk group. I can't help but believe that screening mammography contributed to her death by giving her a false sense of security.

This is a long piece incorporating many of the thoughts I have developed over the last twenty seven years of practicing medicine. The practice of medicine is not an easy task which is probably one of the reasons I was drawn to it in the first place. I believe the recommendation from these two groups have much merit (and a good bit of wiggle room.) American medicine has long been in love with and dependent on technology. Prehaps the best to come of these recommendations (besides an increase in the sale of newspapers) will be some serious discussion between women and their physicians.
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