Last month we were fortunate to have Dr. Vinay Prasad address us at our bi-annual physician leadership forum. We had more than 125 physicians attend to hear Dr. Prasad’s message. He is a highly published and respected hematologist-oncologist and an expert in population statistics and appropriate health care utilization. His latest book, “Ending Medical Reversal: Improving Outcomes, Saving Lives,” speaks to the concept of us having to change our clinical positions about a medical intervention when the contemporary science no longer supports our practice. In my own practice, I was reminded of a scenario some 25+ years ago in which I was asked to coach a physician for inappropriately using negative inotropes (beta blockers) in patients with LV dysfunction (heart failure). Of course, as we know all these years later, this is now the actual recommended intervention - a complete reversal of our clinical practice.
During our forum, we highlighted the gap between the science of population health and individual utilization rates. Using higher cost medical interventions is sometimes more expensive with lower clinical outcomes for the patients we serve. For example, for years many of us were of the belief that a generic should not be substituted for brand-name Synthroid. Years later we learned of the fraudulent activities and that this science was flawed and not correct. Those decades-long practices are hard to break, but are what we need to do to provide quality care for our patients and save them money.
A sample of other issues that come to mind:
Do fetal monitors improve outcomes in low-risk obstetrical deliveries? Does mass PSA screening improve clinical outcome around prostate cancer? Does hormone replacement therapy for post-menopausal patients improve cardiovascular outcomes? Does Swan Ganz Cather monitoring in the ICU improve outcomes? How about routine PCI Stenting for asymptomatic or stable angina or physical therapy for uncomplicated ankle sprains or home glucose monitoring for Type 2 diabetics not on insulin? The answer to all of these questions is no!
I realize to some of you these are highly controversial statements that you may want to debate or outright disagree with. Let me first clarify that neither Dr. Prasad nor I mean to imply that you should never - nor always - do any of these interventions. Instead the message is to continually reevaluate the evidence to make sure we are practicing to an evidence-based medical standard and to “reverse” our position when the science shows our practice to be unsupported. In addition, we emphasized the need to have a clinical standard based upon the science, with the expectation that physicians WILL vary from the standard based upon patient expectations and critical decision making specific to the unique needs of an individual patient. We heard concerns for our patients about the conflicting recommendations from ACOG, ACS, USPSTF and others around breast cancer screening. We heard dialog about current evidence no longer supporting epidural steroid injections for spinal stenosis, yet we heard testimonials as to places where this non-evidence based care persists. All of these represent areas where as physician leaders we need to rise to the occasion and challenge our historical practices. Only in this way will we maintain the trust of our patients in a society filled with direct-to-consumer marketing, conflicting recommendations and web-based propaganda.
However, the idea of “de-adopting” a long-standing practice pattern is clearly a difficult topic.
Just because it is hard does not mean we should shy away from it. Hence, I would like to charge each of us with the responsibility to challenge ourselves and our colleagues to practice to the most contemporary science available. I certainly don’t mean for this to sound trite or demeaning and I recognize how difficult and highly complex these issues are. There are no simple answers and yet only physicians are positioned to truly resolve these complex issues. Failure to do so will invite payors, regulators, lawyers and others to try to do it for us. If we as physicians are confused or unclear, how can our patients possibly know what to do? Again, these are complex issues.
At the forum we also introduced the idea of “Patient Oriented Evidence that Matters,” or POEMS, as many in our audience were unfamiliar with this long-standing approach to reporting on the evidence of care. It is perhaps the most pragmatic way to answer whether or not a clinical practice is supported by the evidence, and must meet three criteria: address a question that primary care physicians face in their day-to-day practice; measure outcomes important to physicians and patients; and have the potential to change the way physicians practice. It could be of benefit to limit your reliance on studies to ones in which the trial was randomized, had at least 100 study subjects and ideally had a “sham” control - meaning the patients believed they were getting the treatment, as opposed to typical controls in which the control group does not believe they are getting the treatment, thus neutralizing the placebo effect. This, coupled with POEM reports, is a great way to keep up in your field without being overwhelmed by the countless number or articles and publications coming at us every day.
So let us pick up the gauntlet and set the standard for practicing to the latest evidence.
Keeping up is no small task and we need to constantly challenge our CME team, our library offerings, our specialty societies and, most importantly, ourselves to rise to the occasion. As we move from volume to value this is an imperative. But don’t do it because of the economics, do it because it is the right thing to do and because our patients deserve it. Begin to talk openly about this, share your experiences, your ideas, or your questions. Join an online forum such as Sermo, Doximity or Medscape. These and other physician settings can aid us all in making a difference on this journey to clinical excellence. I look forward to your feedback and to your perseverance in moving this agenda along.