Evidence Based Decisions and the Art of Medicine

“The evidence clearly shows……”

How often have we heard that argument made, trying to influence our choices or behaviors. Experts provide data that support their point of view, often in the face of conflicting information. We would like to believe that we always make rational decisions based on facts. But human nature proves otherwise. We will base our most recent decision on how the last situation played out. Negative outcomes, even if infrequent, have a greater influence on future behavior than their true weight. And as clinicians we are often told, “Judgment comes from experience, and experience comes from poor judgment.”

So it has been very interesting for me in my new position to work with clinicians and systems on best practices for various patient conditions. Unlike the “hard” sciences like physics, mathematics, and chemistry, soft sciences like medicine and pathophysiology have shades of grey. Even the best designed studies are inherently ambiguous, and the literature tends to further this bias by publishing studies where a beneficial difference is found, as opposed to equivalence or detriment. How do we sort through the data and try to come to a rational conclusion?

By analyzing how to analyze data.



Health service researchers have developed an elaborate grid that attempts to balance the potential benefit of an intervention with the strength of the data supporting that intervention. These decisions subsequently form the basis for clinical guidelines, and in many cases, whether the service will be paid for. The strongest recommendations, IA , are the most stringent , and should be generally accepted. III A findings strogly support more harm than good. You can see where the ambiguity comes in. A IC may well be good, but there’s not strong randomized data. By the same token, a IIIC recommendation not to do something is less of an indictment than a IIIA. As a surgeon, who has spent the last 30 years trying to do the best for my patients, often with limited available data, this is clearly a shift in thinking. We were trained to listen and examine the patient and then determine if they were sick and needed an operation. Subsequently, the specifics of the diagnosis would often be revealed in the operating room.

So why is this new paradigm important? Increasingly, with limited resources, we may be steered to provide or defer therapies based on into what evidence category the question falls. Could “Watson,” when he’s not winning at Jeopardy, calmly crunch all the potential permutations and risks to come to a definitive plan? I suppose he could, but I hope we don’t come to that alone.

When I was still a medical student, Arnie Rosenbaum, an internist in my hometown of Canton, took me on rounds. In each patient’s room, he would sit at the bedside, and take their blood pressure, while gently feeling their pulse. Afterwards, I asked why he would do this when the data were already on the clipboard. “Because I always touch my patients and look them in the eye. It really tells me how they’re doing. And when the time comes for me to be a patient, I hope my doctor makes the same human connection.”

My n=1 in this nonrandomized study of internists in Canton Ohio in 1979. But based on my experiences since then, that’s Level IA data in my eyes.

Making the Tough Choices

Two massive earthquakes – 2 very different patterns of death and destruction
I knew this one would be different than a year ago, when people asked- “So are you going to Japan to help?” The answer was quickly “No, they really don’t need me.” By the same token, my colleague Glenn Braunstein, Chair of Medicine at Cedars and a superb endocrinologist, has been bombarded with requests for interviews and advice regarding potassium iodide to reduce the risks of radiation exposure.

The drama unfolding in Japan is no less riveting than what happened in Haiti, but for different reasons. The patterns of death and injury were not from collapsing buildings or lack of infrastructure – it was rapid and massive related to the Tsunami. The Japanese government is well organized to deal with earthquakes and has teams and supplies available. Building codes are strict. But no one could anticipate the difficult decisions related to the Fukushima Dai-ichi nuclear plant. The risks of additional injury and death are significant, and resources are being poured into the area to minimize harm. Although rescue and recovery operations continue, they seem to have taken a lower priority to preventing additional catastrophes.

What we see in action in Japan is similar to other disaster scenarios - the use of triage. Triage actually originated during the Napoleonic wars with Dominque Larrey, a French battlefield surgeon. He designed some of the first ambulances used on the battlefield, would treat enemy soldiers along with his own countrymen. He recognized that you needed to make a best guess at how to get the most good for the most patients, which may mean not treating those who were likely to die, or would consume disproportionate resources. It is a form of utilitarianism where one tries to maximize benefit for the greatest number, even if the decisions may not be best for an individual.

We saw triage in Haiti, when we were truly resource constrained. Patients that would have survived in the States, were allowed to die comfortably. Others might have quality of life worse than death. Throughout my surgical career, I have been faced with the decisions – they don’t get easier, but after some time, you gain perspective.

Like it or not, we will be performing some type of high level triage if health care in America is to survive. For now, we seem to have unlimited resources, but just because we CAN do something, doesn’t me we SHOULD. Resources spent in futile care, are resources that could immunize a child, provide safe water, or help educate a generation. This isn’t about Death Panels - it’s about having an honest dialogue about where priorities are placed to stabilize the present and build to the future.

There may be a few setbacks along the way for the Japanese. But a year from now, unlike Haiti, they will be back on their feet and stronger with the knowledge of what they learned.

Freedom of Choice

“All around the world, it’s so easy to see. People everywhere just want to be free..."




I am currently over Ontario enroute from Boston. I look down on the landscape of farms, interspersed towns, and the city of Toronto in the distance. It is a route I have traveled often, especially when I was based in Rochester. I fondly remember trips to Canada, and the palpable sense of a difference in tolerance and priorities as I crossed the border. The newspaper in my seat pocket recounts the unrest in the Middle East, and concerns that oil prices rising above $100/ barrel will inhibit Americas own economic recovery. Gas is $4 a gallon in LA, yet, I don’t see any fewer cars on the road.(Driving, in California, is freedom.) There are protests in countries that we normally don’t recognize as foci of discontent – Tunisia and Liberia for example. We wonder what drives people to risk their lives to overthrow a government, when they know that whatever follows could be as equally oppressive. In a commentary, WSJ columnist Michael Novak notes that the desire for liberty is universal and rooted in basic Judeo – Christian beliefs. We talk of free choice, and consequences – whether to eat the apple, whether to accept a deity or idols, how we choose to do business with one another. What I am realizing is that even the replacement of one corrupt government with another, is an expression of the peoples freedom to choose their destiny. Whether extremists can recognize this basic human value or will continue to oppress women and the less well to do remains to be seen.

I am returning from one of my final weekends in the healthcare management course at the Harvard School of Public Health. As we looked at payment systems, it was not surprising that the US high cost for moderate quality paradigm was again examined. Classmates from Israel, the Netherlands, Australia, Canada, and Dubai discussed their own countries; how resources for health care were collected, how they were pooled, and how they were distributed. We fervently debated market pressures, the malpractice environment, and free market competition. Trying to place any of their systems in the US, despite the fact that there was “more bang for the buck,” seemed untenable.

Then we reframed the discussion, and the light went on – it’s all about choice.
Americans are fiercely independent, and pride themselves on being able to guide their own destitny. There is some sense of social responsibility for the less fortunate, but the disparities between the haves and the have nots are extreme. Americans want free choice in whether they drink or smoke, or want to be able to take a medication in lieu of exercise - and they don’t like to wait. This impatient spirit helped us accomplish great things in the past, but may be blinding us to the realities of the present.

There is no question that the American health system is expensive and inefficient. It is focused on technological repair of disease as opposed to a societal understanding of health, responsibility, and support. We realized that by dealing with the economic disparities, many of the health disparities would be ameliorated.

“My God,” you say, “He’s moved to California and is eating too much granola.”

Not so. I believe in technological advances in medicine to reduce suffering. Surgery is one of the most cost effective ways to return someone to health and being again productive. My classmate, who is Chief of Cardiac Surgery at the Hague, does 8-12 case /week – as part of a well organized integrated system in a relatively small country. It has nothing to do with socialized medicine.



Looking at the other countries we discussed, the populations are fairly homogeneous, resources can be concentrated near population centers, and from the time you are a child, there is an understanding that you may need to wait to have your needs met, but they will be. America is vast, we have huge variances in population density and medical resources. There is a safety net available, in public hospitals and emergency rooms but it is not the best way to provide continuity of care.
So how do we tie the unrest in many of the middle eastern countries to public health. And how do we help Americans realize that there must be a change in their perceptions and responsibilities?

It is by understanding that as humans, we want some control of our destiny. Depending on how well our basic needs are met,(remember Maslow’s pyramid?) we are willing to trade some free choice. But when oppression is coupled with poverty, an uprising is inevitable. In a similar manner, American health care is impoverished in the midst of plenty, and the shift must come at the center – with the patient.

Being proactive in your health, making good choices, and partnering with your provider isn’t limiting – it’s the ultimate source of freedom and self actualization.