One size doesn’t fit all

A report from the Center for Medicine in the Public Interest highlights why it’s impossible to “cookbook” medicine.  Both doctors and patients are bombarded by this or that study in both the professional and lay media.  The “standard of care” is assumed to shift violently with each new addition to “evidence-based medicine”.  But so-called evidence-based medicine is in fact epidemiologic-based medicine.   This can give practitioners a fair amount of guidance as to how their patients should be managed, but each patient is unique, every patient encounter its own study where N = 1.  And what is discovered about that “1” often takes priority over a whole stack of impressive, peer-reviewed studies.

Some excerpts from the CMPI report:

[P]hysicians are increasingly seeing the decisions that they and their individual patient reach about a specific treatment plan second guessed by distant “third parties” (working for government or insurance bureaucracies) who, of course do not -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 “guidelines” as the basis for approval or rejection of a particular treatment.

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.

Today’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.

I’ve seen this in my own practice.  A patient insists on being taken off the target for this month’s Hysterical Mainstream Media Prescription Drug Story.  Two months and a fasting lipid profile later, the patient with the heretofore normal cholesterol is placed back on her original medicine, her lipids, her skepticism of studies reported in the news media, and her faith in her physician’s judgment all having gone up.

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