Monday, May 2, 2016

The Dangerous Patient Safety Delusions of Evidence-Based Medicine

Is common sense being overruled by Evidence Based Medicine ?  That is the core argument in this article in The Health Care Blog written by  clinicians, they can lead to clinical errors.  MICHAEL L. MILLENSON  summons Nortin M, Handler M.D. as his muse, stating  the renowned neurologist, Martin Samuels, paid homage to the degree to which uncertainties create more than just anxious rors

No slouch at his own erudite ambivalence about edicts from the National Academy of Medicine,  Millenson comes out as highly suspicious and pessimistic about the evidence based medicine cult which appears to have the  upper hand, becoming embedded in institutional cement.  Some of his reticence results from the seemingly lack  of effect  of evidence based medicine in parts of North Carolina Perhaps this is a local cultural resistance to centralized federal government edicts and perhaps the exception that proves the rule.  The United States is such a large country and has a heterogeneous diverse population both genetically, in socioeconomic strata as well as culturally that one should not be surprised by regional variations.

“The current medical culture is obsessed with perfect replication and avoidance of error. This stemmed from the 1999 alarmist report of the National Academy of Medicine [formerly the Institute of Medicine], entitled “To Err is Human,” in which the absurd conclusion was propagated that more patients died from medical errors than from breast cancer, heart disease and stroke combined; now updated by The National Academy of Medicine’s (formerly the IOM) new white paper on the epidemic of diagnostic error.

Not long after the National Academies published “To Err is Human. Building a safer health system”, a study from the US Veteran’s Administration demonstrated that the preventable hospital deaths due to medical errors was very much “in the eye of the reviewer.”[1] 

In a recent post, the renowned neurologist, Martin Samuels, paid homage to the degree to which uncertainties create more than just anxious clinicians, they can lead to clinical errorsThat post was followed by another  by Paul Levy, a former CEO of a Boston hospital,arguing that the errors can be diminished and the anxieties assuaged if institutions adhered to an efficient, salutary systems approach. Both Dr. Samuels and Mr. Levy anchor their perspective in the 1999 report of Institute of Medicine Report, 

Dr. Samuel's post on THCB is similarly worthy for championing the role of the physician in confronting the challenge of doing well by one patient at a time. Mr. Levy and his fellow travelers are convinced they can create settings and algorithms that compensate for the idiosyncrasies of clinical care. I will argue that there is nobility in Dr. Samuels’ quest for clinical excellence. I will further argue that Mr Levy is misled by systems theories that are more appropriate for rendering manufacturing industries profitable than for rendering patient care effective.

Physicians must not be coerced by government guidelines. These metrics are ruled by the least common denominator, and filtered by ta hierarchy of committees.

America has made a tremendous investment in intensive care units. We have many times the ICU beds per capita as any other resource advantaged country, 25 per 100,000 people as compared to 5 per 100,000 in the United Kingdom. Not surprisingly, when we build them we also build the demand, so-called demand elasticity.[2] The indications for admission in America result in a very different case-mix than anywhere else. We need ICU beds for patients with acute or potentially reversible conditions, but do we need them for the frail elderly or the terminally ill? Maybe the error is not so much in their medical treatments as in the lack of appreciation of their humanity.


Nortin M. Handler, Michael Millenson, 

The Dangerous Patient Safety Delusions of Eminence-Based Medicine | THCB
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