Physician Letter on Mandatory Use of "Best Evidence"

Subject: Mandatory Use of "Best Evidence"
 

Dear Ms. Brase,

According to your website, Minnesota is considering a law to force doctors to use "best practices." As a physician with 35 years of experience and a particular interest in this topic, let me share a few concerns.

The Annals of Emergency Medicine demonstrated that any "evidence" used to create "best practices" involves 12 layers of potentially biased choices, therefore such material should not be viewed as pure and universally accepted. For instance, the "evidence" at Kaiser is a big step down from that at more reliable sources like the American Diabetes Association; Kaiser does not test many obese adults for diabetes despite high risk. And Kaiser withholds oxygen to many heart attack victims; the American Heart Association wants it used 100% in such patients. To whom would you trust your heart?

When I was 3 years old the "best practice" in Chicago was to irradiate thymus glands to make them smaller. So I got that treatment at one of the finest hospital in the city despite being totally healthy. A few years later this was found to be dangerous, as the thymus organizes our immune system for life. The treatment also put me at a lifetime risk of having thyroid cancer. As a result biennial thyroid scans for life are recommended for me and all others who had this wrong treatment.

At another time in the 1970's giving all women diuretics for the swelling of pregnancy was considered a standard or best practice. One of my physician teachers in obstetrics argued that you would never persuade a farmer to do the same for animals. Later it was clear that that best practice was completely wrong and caused harm. The swelling was renamed the physiologic edema of pregnancy. It turns out pregnant women need the extra fluid to withstand blood loss at delivery. Everyone stopped giving diuretics - I have not seen the approach in twenty years.

Sometimes best practices go in cycles. Initially, digoxin was considered a great medicine; then it was withdrawn on about one half the patients, but now digoxin is one of the four required medications for heart failure. And not so long ago the idea that many ulcers are caused by a bacteria - H. Pylori - was so bizarre as to be obviously wrong. Now getting an H. Pylori titer on patients with acid reflux is standard.

Here's one more example: Estrogen was key for solving hip fractures by stopping osteoporosis. Then in 2000 it all got reversed and 90% of the estrogen in this country was stopped. Suddenly it was clear that estrogens can thicken the blood and promote heart attacks.

What should be clear here is that we must allow free thought in medicine so we don't practice lockstep, minimal variation care. Our world leadership as a country in creative medical thought and independent judgment would be at risk. In our race for "evidence" we would toss out the scientific method itself. Science, after all, is only the best explanation of events at any point of time with the highest chance to predict new events - nothing more, nothing less.

The specialty societies get around all these problems by having yearly meetings of EXPERTS to go over changes in thinking. They then publish the trends. The American Diabetes Association, the American College of Surgeons, the American Heart Association, etc. all do this. Such material is the well water from which practicing physicians get best ideas - not rules. I am an instructor for the American College of Surgeons in the subject of Advanced Trauma Life Support which is reviewed yearly with updates followed by full, new texts revised every four years.

The federal government tried to lock everyone into protocols in the past. In 1993, they paid pediatricians and ER docs to publish together the rules on early childhood fevers. In 1995 pediatricians in Utah noted and published that 95% of the good pediatricians weren't following them. It was then decided that care for fevers in that age group could not be set according to someone's idea or even some group's idea of best practice.

The VA is a shining example of the failure of government to run medicine despite using "best practices." This agency feels that computers can replace medical training. They believe they can hire from the bottom and yet have quality by controlling good decisions with popup reminders. Show me one state official who - given a choice - would go to the VA for his or her acute care treatment.

I hope these few examples might prove useful to you. Your policymakers need to know that what they're proposing to do will not work and is not good for medicine or patients. In fact, it does not even lower costs only quality.

Charles Phillips, MD, FACEP

Private Practice - Hospitalist and Emergency Physician

Fresno, California