Artists and Empiricists

This is a cross-post from Ezra Klein’s blog, where Austin and I are guest-blogging this week.

For better or for worse, when I hear people using the phrase “the art of medicine”, I hear an excuse for doing whatever you like. Personally, I’d prefer a little more science and a little less art

Since reading Atul Gawande’s graduation address this weekend, I’ve been thinking about it far too much. That’s partly because I’m jealous of how talented he is, and partly because I don’t think his point can be emphasized strongly enough. He suggested that, when it comes to physicians, we need fewer cowboys and more pit crews. In other words, we as physicians imagine ourselves as heroes working individually, instead of as part of a team, perhaps in a more supporting role.

I think there’s something to this, but it’s only a part of it. We in medicine are obsessed with the new. Whether it’s the latest drug, the newest procedure, or the latest homeopathic cure, we are sure that the thing that’s going to make everything better is just around the corner. This focus, however, means that we spend too little time fixing what we already have.

Take asthma. It’s not like we don’t know how to care for it; we’ve known for quite some time. There are guidelines and evidence, and it’s all there for anyone who wants it. The medicines we’ve used for asthma aren’t new either. Yet, things have not improved:

There is evidence that applying guidelines in clinical practice has not been highly successful. Certainly, examination of available data do not support a positive impact for improving asthma outcomes in the U.S pediatric population at large. Neither hospitalizations, emergency department visits, nor deaths have decreased in children since the inception of the Guidelines in 1991. Because younger children, particularly, have had the highest rate of hospitalization for asthma, and asthma most frequently has its onset during the early years, these data indicate that this 16-year effort to improve asthma outcome in children has thus far been ineffective.

We don’t follow directions. It’s not that we don’t know what to do. It’s that we don’t do it consistently.

Another passion of mine is ADHD. Despite progress in our assessment, diagnosis, and treatment of children with ADHD, researchers have documented wide variations in clinicians’ practices for children suspected of having ADHD. A 1999 national survey of pediatricians and family physicians found that, although about 60% of doctors used formal diagnostic criteria, less than 30% used criteria consistent with the DSM-IV. Another study found that that less than 40% of children suspected of having ADHD were formally assessed with behavioral questionnaires, and DSM-IV criteria were used in less than 40% of cases.  Most importantly, despite strong empirical evidence documenting the benefits of medication use, wide variation was seen in the amount of medications prescribed.

It’s not that we don’t know what to do. It’s that we don’t do it consistently.

Guidelines are meant to decrease practice variation and ensure that assessments and treatments are based on the best available empirical evidence.  Unfortunately, mere publication of practice guidelines does not ensure physician use of or adherence to them.  The survey mentioned above found that 14% of pediatricians and 5% of family physicians in this survey reported adopting a practice guideline for ADHD.

Physicians are often resistant to guidelines because they make them feel unnecessary. They don’t talk about it, but some fear that if a guideline can tell you how to care for a child, you might no longer need a doctor.

We need guidelines, though. We need doctors to learn to practice more consistently, and to use evidence and data. We need them to focus more on implementing what we already know, than in worrying about what’s around the corner.

It’s not as sexy nor as exciting as what you might see on TV, but it’s far more likely to do more for more people than almost anything else you can think of.

We don’t just need fewer cowboys and more pit crews. We need fewer artists and more empiricists.


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