Can EBM and clinical judgment be friends?

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Can EBM and clinical judgment be friends?

My last post seems to have been well received, and I am sincerely grateful for the feedback.  So I hope I’m not being too fastidious or improperly fussy if I take some time here to clarify a particular remark that readers have made in response to the article, either on social media or in the comments section of the post.

And the remark is one generally expressing the following idea:  “Indeed, EBM has serious limitations, we’ve gone too far, and we should make sure to use both EBM and clinical judgment when we are making our medical decisions.”  In other words, art and science. (more…)

Progress note 03/10/2016

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The nefarious FDA…Is Rubiocare “free market?”…In praise of small data…

 

How should a “rational debate” about FDA activities be framed?  Lisa Rosenbaum just published another excellent essay in the NEJM, this time about the decision by the FDA to essentially ban a minimally invasive procedure based on a single adverse event that turned into a high profile case with extensive media coverage.  Rosenbaum decries how the FDA responds to high profile tragedies and always favors consideration of what Robert Higgs has called “user risks”—the risks that come from using a drug or device–and essentially disregards “prohibition risks”—those associated with banning or delaying a therapy.

The “availability cascade” is the term used by Cass Sunstein and Timur Kuran to describe the public outcry that shapes public policy.  Rosenbaum notes that, in response to these highly emotional charges,  “policy debates often degenerate, their crux shifting from ‘Do this solution’s benefits outweigh its risks?’ to ‘Are you good or evil?'”

She ends the essay with a call for more “rational debates.”  But what does a debate about the FDA typically look like? (more…)

Progress note 03/09/2016

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Practicing medicine without an MD…Teaching EPIC to think…More on Trumpcare and the FDA…

Do you need a license to practice medicine?  One hundred years ago, our healthcare system was born on the assumption that the enactment of state medical licenses would be a boon for society.  It turned out not to be the case, but bureaucracies never reverse themselves.  Instead, they create more laws to deal with the unforeseen consequences of the first ones.  Today, you still need a medical license if you are a doctor and wish to practice medicine.  But, as reported by Forbes, if you’re not a doctor but wish to practice medicine, the path to do so is becoming increasingly open. (more…)

Progress note 03/08/2016

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Is there’s no value in looking for value?  Health Affairs has just published an article by researchers at Cornell University who conclude that physician practices spend on average more than $15 billion annually (or $40k per physician) collecting and reporting on quality measures.  This causes Bill Gardner to wonder if we couldn’t find better value for the money.

But wasn’t the whole point of this spending to find value in the first place?! (more…)

Progress note 03/07/2016

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Are all certification outfits created the same? Should the government impose free market features? Any pro-market health economists out there?

H.L. Greenberg wrote a scathing indictment of board recertification last week in Medical Economics.   He makes excellent points regarding “quality” but he also argues that board re-certification process offered by NBPAS as an alternative to the ABMS’s MOC, is itself problematic and unjustifiable.  On what grounds can NBPAS claim to measure quality?  Greenberg’s point is valid, but only to an extent.  The real issue is that board certification is mandated by hospital regulations, which are themselves established under strong governmental pressures.  That leaves physicians with no margin of maneuver away from this arbitrary and coercive system.  If MOC or certification was not mandatory, there would be nothing wrong with physicians electing to pay an independent organization (like NBPAS or any competing organization, including ABMS) to verify their competence by whatever means is mutually agreeable.  Whether this arrangement would or would not have any traction with patients, who are the ultimate determiners of quality, is a separate question. (more…)

Progress note 03/03/2016

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Trumpcare, research parasites, Lown Institute advocating for free-market medicine?…

Donald Trump has released his healthcare proposal in a few bullet points.  I find little to object to.  He would remove the awful individual mandate, which would essentially kill Obamacare.  His most interesting proposal is to allow the importation of drugs from overseas (he must have read my blog!).  The left will find it hard to argue against this (Vox conveniently ignored that point in its coverage of Trumpcare yesterday), and so will the hypocritical right.  If Trump is elected and serious about this measure, he will find opposition from Pharma but also, I predict, from the FDA (Big Pharma’s most trusted ally). (more…)

Progress note 03/02/2016

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Racism in healthcare, irreproducible science, screening athletes…

The NEJM has published a piece on how to deal with racist patients.  As expected, the solution comes in the form of an algorithm…By the authors’ definition, racist or ethnic biases toward physicians falls into two categories: justified (say, because of historical wrongs) and unjustified.   The latter is called bigotry.  Distinguishing one type from the other is “straightforward.”  Ethicists apparently have no sense of irony or circular reasoning. (more…)