Doctors are Not the Problem but They Continue to Blame Them for All the Evils!

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I was about to post the blog post on Hillary versus Obamacare /the Affordable Care Act, however I read a Harvard study suggesting that 1 in 4 doctors are “cowboys” who like to go rogue.

The report states that about one in four doctors have a “cowboy” approach to medicine, and that they could be responsible for hundreds of billions of dollars in wasted health care spending the new Harvard study summarizes. It was based on survey responses from about 600 cardiologists and 935 primary care physicians. The authors defined 25% of the PCPs as “cowboy” for consistently administering non-evidence-based treatment, and suggest that these doctors’ decisions represent roughly 35% of end-of-life Medicare expenditures and 12% of overall Medicare spending. Altogether, “cowboy” doctors may represent about 2% of the nation’s gross domestic product-therefore the hundreds of billions of dollars.

Many doctors ‘are relying on their own beliefs; those “cowboy” decisions are often based on decades of medical experience and instincts that save patients. Our system of health care and government regulations and malpractice attorneys force us to make decisions based on a system that consistently punishes us for the exceptions that inevitable occur if we practice pure statistical medicine.

This article also presumes that every condition and patient situation has high quality evidence based support. If you look carefully at the article one notices that they do not say these docs are practicing against evidence – only that they administer non evidence based treatment. Many of my own recommendations ass a physician are based on careful judgment because no evidence or guidelines exist for every patient’s situation.

The evidence that they want us to believe is that most conditions get better on their own. So why not save a bundle and eliminate hospitals and doctors entirely.

Soon these docs will be replaced by salaried “noctors” fully compliant with whatever evidence-based approach their preprinted algorithm tells them to do. There will be no room for judgment-based decisions,

What no one realizes except those on the “front-line” of delivering health care is that patients do not always follow the textbook! Sometimes you take certain actions because a patient just doesn’t “look right”. You cannot possibly spell that out on an algorithm, and that ability only comes from years of experience. “Studies” like this serve no purpose other than blaming and punishing doctors for using their hard-earned experience to take care of their patients!

So we have peer review rings, bot-generated (automated computer program designed to assist in the diagnosis and treatment plans) articles getting by peer review, and an all-time high level of retractions and article fraud, yet we are supposed to trust Evidenced Based Medicine/EBM like never before?

And guidelines are based on studies in which the study population was cherry-picked, but we are taking care of the outliers and real-world populations who would have been tossed from the study populations and therefore don’t fit the guidelines….

And when your bureaucrat-doctor (or just plain bureaucrat) decides to cram “population medicine” down my throat instead of taking care of the patient in front of me, I am now a cowboy (or cowgirl, as the case may be)?

Consider the specialty of psychiatry, it’s very hard to stick to evidence-based techniques and get good results. If it were easy, then 100% of depressed patients would get better on their first SSRI (commonly used antidepressants) or after their first 10 sessions of CBT (a form of psychotherapy), and we wouldn’t even need psychiatrists.

There are a few large reasons why we will always be practicing evidence-free medicine. One is that we don’t know what to try in the proper sequence. Enormous amounts of people don’t get better on the first try, and from there, the evidence gets progressively weaker. There are only a few trials of sequenced or stepped interventions, and there are many patients who can’t or won’t participate in certain of the steps. And so then you’re in a zone of evidence-free medicine.

The famous stepped trial of STAR*D had patients trying sequenced interventions, but many people in STAR*D never got better. So what do you do when the evidence-based stuff doesn’t work? Literally, nobody knows.

Another large reason is that people are more complicated than volunteers who sign up to be in clinical trials. Yes, SSRI’s have been studied for depression. But is an SSRI the right choice for a depressed, controlling, brittle narcissist? Never been studied.

What is the best approach for a patient with a huge paternal transference to the psychiatrist, who always sees him as the stern father he was never able to please? Never been studied.

What’s the best approach for treating a masochist who says they have “bipolar” but actually always self-sabotages in some kind of perpetually depressive wish fulfillment? Its never been studied!

And those things probably won’t ever be studied, or for that matter, can’t be studied. And yet the clipboard carrying people from Quality want us to use evidence-based interventions.

I remember years ago when the powers that be eliminated the use of “ranged orders” for Hospitals. [e.g. Morphine sulfate 1-10mg IV q 1 hour titrate to pain were standard orders in the CCU at the hospital in which I trained]. The alleged problem with these orders was ” you are making the nurse prescribe the medication.”, to which the proper retort should have been, “No, I have prescribed a medication, and am expecting the trained nurse to observe the patient, and adjust treatment, within certain parameters, based on the patient’s needs and response”. Instead as group, we rolled over, and let the bean counters change the way we practice. At the time I said the goal was to make the orders so that a “trained chimp” could give the medication. Perhaps, more accurately, would be that a trained algorithm could prescribe and administer the medication.

There is evidence about what “works” and then there is real life. Evidence based medicine is based on statistics. All well and good! The problem is we treat individuals, not statistics. So called evidence based medicine is a good thing to keep in mind but it’s far from the only thing. That’s why our job as clinicians cannot be reduced to an algorithm. And never will be. ACLS (Advanced Cardiac Life Support) is a perfect example. Something to consider but if followed exclusively the results will not work out well for the patients. What does ACLS say about beta blocker overdoses as a cause of bradyarrythmias (slow heart rates)? Are we as physicians cowboys when we use a transvenous pacer when needed rather than the ever popular but less effective transcutaneous? And understand when to use which? Even if the algorithms don’t? What we do know is that PA/NPs (our physician substitutes) who follow algorithms increase cost and fail to understand critical distinctions of pathologies. That’s fine if the patient will improve no matter what we do, which is often the case. Understanding when thought is required however is more problematic, that’s our job. There is no thought involved with an algorithm. But if you want us all the same then just use a machine. Enter data in a computer and have the computer tell a nurse how to treat the patient.

The fundamental problem with evidence based medicine is that the evidence keeps going ’round and ’round. Ipso facto (?), nobody really knows what’s best so you just go with whatever works. Its a shame that medicine is so messy. Should we feel so sorry for the bureaucrats? Only if they are impacted by the computer algorithms.

But doesn’t that make it so much easier to administer, quantitate, control, study, perform statistical analysis, approve or deny treatment? Trying to control independent doctors, who think they can practice medicine according to their personal wisdom, knowledge and insight, is like herding cats.

The study sought to explain regional variations in healthcare expenditures. IMO, the use of the word “cowboy” (and its counterpart, the “comforter”) is inflammatory. As we know, “cowboy” indeed suggests a rogue, someone who freely and carelessly, or aggressively, manages patients, pushing the envelope of care while incurring some risk for patients.

Here, the HBS team uses the term “cowboy” to mean someone “whom consistently and unambiguously recommended intensive care beyond those indicated by current clinical guidelines”. A “comforter” follows the clinical guidelines. The surveys are based on 3 short clinical vignettes, all of which focused on the patient with stable angina or heart failure – and the term “comforter” arose from an emphasis on palliative care in these vignettes. The foundation of the paper is the published clinical guidelines on the long-term management of these conditions: The authors believe 100% of practicing physicians should be following these guidelines, including discussions about palliative care with the patient when appropriate (e.g., high-risk heart failure already on maximal treatment). Any variation from practice guidelines may be explained by any number of variables (including malpractice environment, payment structures, patient preferences, etc.), but their data suggested the overriding factor was “physician beliefs”.

The authors conclude, “Physician beliefs play a large role in explaining such [regional healthcare expenditure] variations. A better understanding of both how physician beliefs form, and how they can be shaped, is a key challenge for future research.” The authors go on to estimate the healthcare expenditures associated with such intensive care. IMO, drawing this conclusion from a survey based on 3 short clinical vignettes (all cardiac), is fraught with problems, but some of the points of the study are not unreasonable.

The choice of the word “cowboy” leads of course to the MSM picking this up and further misrepresenting the data. The physicians in this study did NOT prescribe snake oils or shady treatments, but rather 1) would have followed patients more frequently than the guidelines suggest, and 2) would not often have raised the issue of palliative care with patients in end-stage, advanced heart failure.

This is just the first of many similar studies that will highlight that we can save money by following guidelines that restrict care. This is paving the way for rationing, just trying to make us feel better about it. We are doing what is “right” by following the guidelines and not treating our patients.
As stated above, our patients are humans, not numbers. Treating them like numbers makes it easier to say we are not going to prescribe that medication, perform that surgery, or offer that treatment because you simply are not worth it anymore – too sick, too old, not productive, etc.

We already do ration care. We’ve rationed care forever and we always will. Moreover, it’s completely appropriate. However, “Evidence based medicine” raised the cost of a colchicine tablet from 5 cents to 5 dollars. It is about to do the same with the newly branded vermox. Evidence based medicine is subject to the same corruption as anything else.

Part of the high cost of medicine today came from Medicare’s decision to spend as many taxpayer dollars as physicians requested, without sufficient review. That led to a marketplace than can tolerate $50,000 medications and $250,000 surgeries. It is entirely appropriate for taxpayers to have an interest in how their money is spent.

But rationing has always been with us. The only way to avoid rationing is to quit charging any third parties altogether and contract directly with the patient. But then it’s the patient’s own financial resources that control the rationing. So rationing will always be with us in one for or another.

This is not an argument in favor of cookbook medicine or mandatory algorithms, by the way. The problem with rationing care is when you try to do it by following a “guideline” or algorithm. For example, a hip replacement after hip fracture may be extremely appropriate in an 80 year old that is active and plays golf every day, but not so much in the 65 year old nursing home resident who has had a stroke and doesn’t know they are in the world. All patients are not the same, and if treating my patients as individuals rather than just a diagnosis makes me a cowboy, well then, maybe I am! The proper practice of medicine is doing what is best for the individual patient, not bending to the whims of a broad statistical set with all its biases. Often “The Evidence” is wrong. Medicine, as most of us clinicians realize, is an art more than a science.

There are always going to be a few bad apples in the barrel, and we hear about those practitioners in the media, which loves to exploit anything which denigrates physicians.

My final comment is that EBM has plenty of supporters among admin and “high up” physicians.

It is interesting that the paper came out of the Harvard Business School, not the Medical School, by people whose expertise is counting money, not taking care of sick people. They use an outmoded concept of evidence-based medicine, perhaps because they know no better or perhaps because perverting a good idea better fits their agenda; and they seem to know nothing about narrative-based medicine. Consider, though, that a single case report is evidence, too. If we find that an individual patient did well on an approach that is not in the guidelines, we owe it to our colleagues and future patients to write up the case and send it to a journal.

I think evidence is great, but evidence is always changing and the times/environment/particular patient cannot be overlooked – medicine is an art to all those writing horrid misplaced inaccurate journalism that have forgotten.

I pray that the art of medicine will not be forced into extinction by the aloof, arrogant Harvard academics that see patients as points along an algorithm. We train physicians to come to treatment decisions by looking at the patient as an individual. How many times has a technician failed to fix your car because the computer failed to give him a fault code. Truly good physicians and mechanics will always consider the problem as an individual issue that needs careful analysis based on it’s unique presentation. A cold guideline will fail frequently. We just have not come to the Star Trek age yet!

Rogue doctors would be better defined as those doctors who showed up to the houses of the authors with axes and chainsaws

After 30+ yrs of practice the bureaucrats in Washington will finally control us physicians. The implementation of the EHR will give the bureaucrats the means and opportunity to penalize anyone who doesn’t follow guidelines, the patient be damned. All you have to do is look at the Veteran’s health system to see this. The bureaucrats do what they want and only worry about their bonuses and “junket” trips to Las Vegas. If they think this will save money and lives they are a perfect example of how it won’t. But by that time no one will be able to do anything about it.

Put those “experts” on a horse and see how far they get. More lives are saved in the ER by experience than by cookbook statistics.

I am old enough to have seen that teachings that once were dogma are now dog shit. Just take care of your patient to the best of your ability and everything else will take care of itself. You can always tell the pioneers/cowboys by the arrows in their back.

There is no art to evidenced based medicine.

“Evidenced-based medicine” is not always the best medicine! You have to THINK rather than follow the herd as academic and public health medicine wants us to do.
The “evidence” is often compiled from studies that require a limited base of patients, free of co-morbid conditions for a good reason. In real life, we treat the true multifaceted and multiorgan problem patient.
Cookbooks are great for baking cakes but poor for medical care-and this is where Obamacare is going; standardized, mediocre-care . Look at the idiotic questions the Obamacare physical requires-in many ways, more a political document.

I would think Cowboy doctors SAVE lots of money. We often don’t order things that are unnecessary but that our colleagues insist upon to cover themselves. We are comfortable taking the risk and leaving our judgments exposed to second guessing.

Overall, it just makes me very sad that drivel like this is given so much gravitas and control over our lives as physicians and patients. Very sad, indeed!

Hopefully we will come to our senses and see the light or God help us all!!!!!

Unless this is what we all really want and are comfortable with including rationing of health care and the possible “death panels”.

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