Will there be an exam in this course (of treatment)?

Perhaps you saw the news yesterday that all those medical tests that were supposed to be so important for our health now aren't?  This is the slippery slope of 'evidence-based medicine' -- it leads to recommendations based on evidence!  Which, if the panel recommending this is right, and it consists of nine medical specialty boards (Internists, Nephrologists and so on), will lead to less unnecessary medical expenditure in the US, and equal or better health outcomes.

The initiative is called "Choosing Wisely", and each of the medical boards involved in this initiative (and more are slated to join in the fall) proposes a list of "Five Things Physicians and Patients Should Question", and you can find those lists here. The lists are aimed at encouraging physicians and patients to choose care that is "Supported by evidence, Not duplicative of other tests or procedures already received, Free from harm, Truly necessary." 

These aims are pretty basic and even obvious, don't you think?  Indeed, why invoke them so late in the game?  As the New York Times story says,

The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.

You know that, just as when limits were proposed for prostate and breast cancer screening several years ago, many will protest this as health care rationing, which we don't accept in America (unless, of course, it's rationing by ability to pay, which is completely acceptable, because who in this country cares about people poorer than themselves?).  There truly are limited medical care dollars, and decisions do have to be made about how to spend them.  If unnecessary but costly testing is curtailed, physicians, equipment companies, testing centers, anyone who now profits from these tests, stand to lose.

But, insurers call the shots, and if they are beginning to refuse to pay for these tests, the way medicine is practiced has to change.  Okay.  We all know our medical system is profit-driven, and decisions get made based on the bottom-line.  And, as a result, we all know horror stories -- the woman who was sent home from the hospital 3 hours after a double mastectomy, insurance companies refusing to pay for emergency room visits for emergency treatment, and so on, decisions based on optimizing the bottom line rather than clinical outcome.

We also do know, of course, that our noble peers in the legal profession are crouched, ready to pounce, in the way of lucrative malpractice suits.  And what that understandably does to doctors and their decisions.  And the role of testing by doctors who have ownership in testing facilities.

But, the idea of basing these recommendations on evidence is interesting, even if it's only part of the story.  High tech medicine is, well, technology-driven.  It's clear from the lists of tests that this initiative now says physicians should no longer routinely order that the results are often not definitive, and don't change clinical practice or outcome.  So why did they become routine?  It's profit, hand in hand with the legal department.  When the salesman comes around with some new toy, at a hefty price tag, it is difficult to resist the undoubted statement that "this will enable far better diagnosis and care for your patients", and will put you ahead of your peers who only have last-year's model.....

But why are these tests, developed by very smart, highly skilled engineers, not definitive?  Because of something we write about here on MT all the time -- causation is complex.  And if you don't know what you're looking for, or what your findings mean, if anything, no matter how many tests you do you're not going to affect the outcome.  And despite the best science, societal vested interests (demanding patients, mediocre doctors, malpractice risks, profit motives, issues related to 'evidence based' decisions, and so on) come into play.

So while we like to think of medicine as a fine technical science, in many ways the complexity of the causal landscape as well as societal issues have largely become the defining factors in clinical outcomes.  Science is one consideration, but given the realities, not the only and perhaps often not even the main one.