Diversity and Clinical Evidence
The evolution of the species and the evolution of science both depend on diversity, even polarization. This morning our flight cleared customs at something like 4 am. I did not know the other doctors arriving from other parts of the world, so I started looking for European looking types who might be part of the group. We were coming to Fiji to help with a highly promoted health festival, the first of its kind in Fiji. The first bookish looking gentleman I approached turned out to be a doctor of economics from Manchester. Overhearing our conversation two of the surgeons materialized, one an ENT from Germany, the other from Wisconsin, a thoracic surgeon. With quite a bit of time on our hands and no other interruption there was one of those spontaneous discussions about the economics and shortcomings of medicine as practiced in various countries. The range of assertions would make for a credible seminar.
The economist described a program in England seeking a high standard of care based on carefully researching best practices in arriving at standard treatment protocols, so that everyone would receive the best treatment. The discussion became intense.
You know how you will argue a point to yourself long after an encounter wishing you had said--. Well the question kept turning over in my mind and it was much later at a dinner meeting, looking at the diversity of the people who make up the leadership of Fiji that it struck me.
For a treatment to evolve in such a way as to advance the science of medicine there must be diversity. The question of why and why not must be asked repeatedly and from different viewpoints. Publish the results of trials, yes. Even suggest best practices but do not codify. This diversity is the necessary DNA for the evolution of science just as it is for evolution of the species.
Just because a series of studies seems to establish or give best, evidence of the preferred treatment does not mean every physician will or should accept it. The physician may have a great familiarity with a less expensive or less risky earlier protocol. He or she may want to wait for further evidence of success with the suggested treatment in the local community. There may be a compelling contrary view articulately expressed by a respected colleague.
You don’t have to be around medicine long to observe the changing trends in treatment. What is well supported today by clinical studies may be heresy tomorrow based upon new findings, which may or may not be valid. The prudent physician waits a bit to see what happens. He may himself suspect the proposed best practices as being a trend that is likely to change. Often more credence is afforded current studies than better, more valid older publications.
For example: there was an assertion in the not too distant past that heparin was of no benefit in the treatment of MI other than as a prophylactic for DVT. I dare say the doctors in the trenches were less enamored with this contention than were the cardiologists quoting very good studies. Indeed, the worm turned. A decade later heparin was again first line treatment for coronary occlusion.
Treatment studies today require careful scrutiny. Many studies are paid for by drug companies who have millions riding on the outcome of the study. Even in a carefully done double blind study, it is difficult to eliminate bias as an independent variable.
Once a course of therapy becomes codified as supported by best evidence, it stops being questioned. It stops evolving. Then there is the question of just who makes the judgment on the evidence. Such judgments are ripe for economic or political distortion. Diversity is based on medical judgment and if it is wrong, that judgment does not mislead others but rather serves as a reference. This is not experimentation but clinical evolution, a diversity of good clinical options for a diverse population.
The best clinical judgments and thus management evolve from the bottom up, starting with the patient and then the clinician. That choice of best treatment must be made at the grass roots, at the clinical level! Government and insurance interests should not interfere. The best public health measures, on the other hand, come down from the top, the CDC, etc. One must be clear which system is involved. Immunizations, epidemiology, isolation and the environment require authoritarian control from research and public health officials, hopefully they are up to the task, and the clinician should not interfere.
The very protocol based on the best science and the best evidence once mandated, negates the very science and statistical studies upon which it is based. Without the diversity, dynamics and open source collaboration of the scientific method, without the inductive reasoning, the very quality the very excellence, which is sought, is lost as is the progressive evolution of medical care.
The economist described a program in England seeking a high standard of care based on carefully researching best practices in arriving at standard treatment protocols, so that everyone would receive the best treatment. The discussion became intense.
You know how you will argue a point to yourself long after an encounter wishing you had said--. Well the question kept turning over in my mind and it was much later at a dinner meeting, looking at the diversity of the people who make up the leadership of Fiji that it struck me.
For a treatment to evolve in such a way as to advance the science of medicine there must be diversity. The question of why and why not must be asked repeatedly and from different viewpoints. Publish the results of trials, yes. Even suggest best practices but do not codify. This diversity is the necessary DNA for the evolution of science just as it is for evolution of the species.
Just because a series of studies seems to establish or give best, evidence of the preferred treatment does not mean every physician will or should accept it. The physician may have a great familiarity with a less expensive or less risky earlier protocol. He or she may want to wait for further evidence of success with the suggested treatment in the local community. There may be a compelling contrary view articulately expressed by a respected colleague.
You don’t have to be around medicine long to observe the changing trends in treatment. What is well supported today by clinical studies may be heresy tomorrow based upon new findings, which may or may not be valid. The prudent physician waits a bit to see what happens. He may himself suspect the proposed best practices as being a trend that is likely to change. Often more credence is afforded current studies than better, more valid older publications.
For example: there was an assertion in the not too distant past that heparin was of no benefit in the treatment of MI other than as a prophylactic for DVT. I dare say the doctors in the trenches were less enamored with this contention than were the cardiologists quoting very good studies. Indeed, the worm turned. A decade later heparin was again first line treatment for coronary occlusion.
Treatment studies today require careful scrutiny. Many studies are paid for by drug companies who have millions riding on the outcome of the study. Even in a carefully done double blind study, it is difficult to eliminate bias as an independent variable.
Once a course of therapy becomes codified as supported by best evidence, it stops being questioned. It stops evolving. Then there is the question of just who makes the judgment on the evidence. Such judgments are ripe for economic or political distortion. Diversity is based on medical judgment and if it is wrong, that judgment does not mislead others but rather serves as a reference. This is not experimentation but clinical evolution, a diversity of good clinical options for a diverse population.
The best clinical judgments and thus management evolve from the bottom up, starting with the patient and then the clinician. That choice of best treatment must be made at the grass roots, at the clinical level! Government and insurance interests should not interfere. The best public health measures, on the other hand, come down from the top, the CDC, etc. One must be clear which system is involved. Immunizations, epidemiology, isolation and the environment require authoritarian control from research and public health officials, hopefully they are up to the task, and the clinician should not interfere.
The very protocol based on the best science and the best evidence once mandated, negates the very science and statistical studies upon which it is based. Without the diversity, dynamics and open source collaboration of the scientific method, without the inductive reasoning, the very quality the very excellence, which is sought, is lost as is the progressive evolution of medical care.
posted by Clancy Hughes | 9/10/2004 01:00:00 PM
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