Dr. Jerome Groopman holds the Dina and Raphael Recanati Chair of Medicine at Harvard Medical School and is Chief of Experimental Medicine at Beth Israel Deaconess Medical Center in Boston. He is also a staff writer for The New Yorker. His latest book is How Doctors Think. He makes this observation in an interview in the Dec. 17, 2009 New York Review of Books.
As you read this excerpt, think about how closely it relates to the current Race to the Top and LEARN (sic) initiatives coming from Washington, D. C.
Jerome Groopman: [T]here are important reasons for having a scientific statistical analysis of evidence. I'm a scientist. I'm a professor at Harvard. I've done the clinical trials in my own field that have led to such "evidence." But I'm also acutely aware of their limitations. Statistical analysis is not a substitute for thinking. [emphasis added] Unfortunately, to my mind, because I voted for President Obama and certainly support many of the current reform efforts, there is a very powerful group with an ideology emphasizing evidence-based medicine, what they call "best practices." That is a wonderful term, because how can you argue with best practices?
But if you look at some of the bills, like the House bill, HR3200, and you look at many of the incentives in the Baucus bill from the Senate Finance Committee, they clearly want doctors not to think and lead, but to simply follow. And the incentives are that you are paid more by adhering to specific guidelines, and according to some proposals, your malpractice liability will be tied to whether you follow guidelines or not.
Now many times, there are patients whose illness don't conform to the direction of guidelines. Many people do not realize that in general the committees that draw up clinical guidelines force a consensus and there are often experts who disagree with some aspects of the guidelines or contend that they are flawed. There are numerous examples of this that are familiar to the public. One was the treatment of nearly all women after menopause with estrogen to prevent heart disease and dementia. We now know that the case for such treatment is far from clear and some credible experts had doubts about it from the start. A recent analysis of more than a hundred evidence-based conclusions about clinical practice reported that after two years more than a quarter of the conclusions were contradicted by new data, and that nearly half of the "best practices" were overturned at five years. This shows that guidelines are not gospel from a scientific point of view. Also, patients have different goals with respect to how much treatment they want, what kinds of treatment, and frankly, how much they are willing to comply with prescribed treatment. And you are punished in this system if your patients don't comply.
And so what's happened in Massachusetts is that patients who are in most need of a caring and communicative doctor, patients who are confused about their treatment, patients who are resistant, patients who don't like to take pills, diabetics who are too poor to eat healthy food--all of these patients now may be shunned by physicians because of the risk that you're going to look bad on a report card. I just learned of an older woman who was very fragile and in the midst of heart attack whose cardiologist hesitated to perform a necessary procedure to open the coronary arteries because her outcome might well be poor, and this could be counted against him in assessing his performance. These are the unintended consequences of much of the movement for what is called "pay-for-performance."
Education Research Sucks (But We Knew That)
From Susan Ohanian: