“THAT’S NOT WHAT I WANTED TO HEAR!”: EVIDENCE-BASED MEDICINE AND OUR HARD CHOICES

By Jessie Gruman

April 2, 2014

On October 4^th, 2011, I delivered the Alex Drapos Memorial Lecture at Clark University as part of their ongoing President’s Lecture Series.’  Here’s what Jim Keogh, Director of News and Editorial Services, reported about my talk:

Gruman said American health care treads a fine line between trying to serve the good of the many and the interests of the individual. But no one has yet figured out a cost-effective, yet humane, way to do both. She asserted that the skyrocketing expense of health care ‘ expected to rise to $4.64 trillion by 2020 ‘ isn’t reflected in the quality of treatment people receive.

‘Should we be able to choose whatever medicine we want, even if there’s no evidence it’s effective?’ ~ Jessie Gruman

‘There is much ineffective, extra, inappropriate care being delivered,’ Gruman said. As an example she cited a study showing that only 21 percent of people receive beta blockers following a heart attack, despite the fact that it’s one of the most effective treatments for that condition.

She noted that the chief actuary for Medicare has labeled 15 percent to 35 percent of health-care expenditures as ‘wasteful,’ and that $75 billion to $150 billion could be cut.

Gruman advocated ‘evidence-based medicine,’ care that is deemed effective based on the ‘strongest clinical evidence.’ Evidence-based medicine often clashes with the desires of the individual patient, who may seek treatment he or she believes will work, but which has not been proven effective through objective measurement. She noted some common misperceptions:

• If the doctor orders a treatment, it must be needed.
• A doctor is ‘bargain shopping’ if he or she orders a less expensive treatment.
• Clinical care does not vary much among doctors at a hospital.

Gruman said some patient-advocacy groups want unfettered access to screening technologies and branded drugs when less expensive options are available. Pharmaceutical and medical device companies find it in their best financial interest to maintain the status quo, she said, and they, and others who object to an evidence-based policy, are often abetted by the media. She recalled the emotional public hearings held about the Food and Drug Administration’s recommendation against the drug Avastin as a treatment for breast cancer. At the hearings cancer survivors insisted Avastin worked, despite evidence to the contrary. Gruman said the media framed the debate as ‘heartless bureaucrats’ ignoring the women’s heart-wrenching testimony.

These types of villains-vs.-victims storylines impede the progress of instituting evidence-based medicine policies, Gruman said. ‘Should we be able to choose whatever medicine we want, even if there’s no evidence it’s effective?’ she asked.

Gruman said she is deeply sympathetic of the patient’s plight, and that human instinct is to take any measures possible to preserve a life. She herself was the beneficiary of ‘long-shot’ chemotherapies and radical surgeries.

The truth is that the current health-care delivery system is unsustainable, she said, noting that a family of four pays an average premium of $15,000 for coverage, but convincing the public that evidence-based health care can be effective at a lower cost is a difficult challenge. It’s critical that people become better informed about their health care, Gruman said. ‘The rates of health illiteracy and innumeracy are appalling,’ she said.The hurdle is that health-care is a ‘monstrously complex’ issue to research, understand and change.

‘I think we’re in for a rough ride here,’ she said.