What the Reduction in Tonsillectomies Teaches Us About Medicine

The following originally appeared on The Upshot (copyright 2014, The New York Times Company).

When I was a child, one of my favorite books was “Curious George Goes to the Hospital.” It told the story of a little monkey who swallowed a puzzle piece, needed an operation to get it out, and got ice cream to soothe his sore throat afterward. It seemed at the time to be a thinly veiled story about tonsillectomy. One of the driving forces behind the publication, I’m sure, was that so many children had their tonsils removed that it was helpful to have a book explaining to children how such a hospitalization would go.

Today you’d be hard pressed to find many normal children who have had their tonsils removed. That’s not because we cured tonsillitis in some way. It’s because, in large part, Jack Wennberg brought data to the fight.

Dr. Wennberg is an epidemiologist who noticed in the 1960s that enormous variation existed in the ways that physicians practiced medicine. For instance, in one Vermont town, about 70 percent of all children were having their tonsils removed by the time they reached adolescence. In another town nearby, only about 20 percent of children had the procedure.

There were no differences in the children in these two places. Tonsillitis was not more common in one town, and the children were no more or less healthy before or after the procedure. The doctors just seemed to have very different attitudes toward how to take care of tonsils. And when Dr. Wennberg started presenting his data to the doctors in the first town, they changed their practice. They started doing even fewer tonsillectomies than those in the second town. Not only that, but they started to define strict criteria for who should have the procedure. They started to practiceevidence-based medicine.

Since then, the arc of medicine has been pushing more and more toward an approach that is more scientific and focused on data. This conflicts, however, with the way that medicine was practiced for generations before. It has resulted in a growing rift between those who believe medicine is an art and those who believe it is a science.

Those who think it a science have continued to point out huge variations in care that don’t lead to better outcomes. The Dartmouth Atlas is full of such studies that show that all over the country, physicians practice in radically different ways.

This would be fine if care were cheap, or if it didn’t sometimes cause harm to patients. Unfortunately, both of those things are untrue. Research shows usthat in areas where people receive more invasive and intensive therapies, they often fare no better, while paying much more.

Guidelines are meant to try to combat this fact. Groups of experts try to come up with plans of care that follow evidence and data. They dictate that for certain patients who meet certain criteria, certain practices should or should not be done. It’s an attempt to replicate what happened naturally for tonsillectomies decades ago.

To some, this seems like common sense. There are times when we know what the best course of action is for certain diseases, and applying the standard of care is a no-brainer. In medicine, however, this still remains difficult to pull off.

study published just before I started residency found that only two-thirds of pediatricians knew that a guideline existed for jaundice. Only half knew that a guideline existed for ear infections. Only 16 percent knew one existed for preventive care. Even among those pediatricians who knew of guidelines, most did not change their practice because of them. They believed that, for the most part, the guidelines were “not helpful.”

Because of this, infrastructure was increasingly put in place to “encourage” doctors to practice in certain ways. Formularies (restricted lists of medications available) attempt to limit the doctors’ choice of drugs. Prior approval from insurers is necessary to do certain tests or procedures. These are ways to try to get physicians to practice more uniformly, and to try to remove unwanted variation.

Some doctors believe that this is actually harmful. They believe that patients should be treated as individuals, and think that guidelines, and evidence-based medicine, are too “cookbook,” remove doctors from the equation, treat patients all the same, and result in missed opportunities for better care.

Given the advances made in recent years in personalized medicine and the human genome, such arguments are being given renewed weight. A growing body of literature indicates that we can identify individual traits, including whether certain medications will or won’t work in individuals ahead of time. No guideline could predict this.

The real problem here is that this debate is viewed as “either/or.” That’s just not the case. Guidelines aren’t meant to tell you how to take care of every patient. They’re meant to tell you how to take care of specific patients. They tell you that for certain patients who meet certain criteria, there is a best way to practice.

But a physician still must decide when a patient doesn’t meet the criteria, and if not, must treat that patient using judgment and experience. Guidelines don’t cover everything, but we should allow them to cover what they can.

It’s a good thing that when I read my children “Curious George Goes to the Hospital,” they had no idea what a tonsillectomy was. That wouldn’t have happened without evidence-based medicine. We need it, along with physician judgment, to continue to improve the way we practice.


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