By PAUL LEVY
Is this a case of ethical blinders?
Today's New York Times has an important story about the ineffectiveness of removal of lymph nodes for certain women with breast cancer. That is a significant result of clinical research. But read this:
Experts say that the new findings, combined with similar ones from earlier studies, should change medical practice for many patients. Some centers have already acted on the new information. Memorial Sloan-Kettering Cancer Center in Manhattan changed its practice in September, because doctors knew the study results before they were published.
And they felt no need to spread the word quickly to other hospitals and to breast cancer patient advocacy groups and help women across the world avoid the surgery and its after-effects? (As noted in the article, "It can cause complications like infection and lymphedema, a chronic swelling in the arm that ranges from mild to disabling.")
Paul Levy is the former President and CEO of Beth Israel Deconess Medical Center in Boston. For the past five years he blogged about his experiences in an online journal, Running a Hospital. He now writes as an advocate for patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement at Not Running a Hospital.
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I agree with Craig’s points. Although you may rightfully bemoan the lag in adoption of best practices in medicine (and I would vigorously agree with you), medicine is also replete with situations where everyone jumped on the bandwagon for a new treatment which was later found to be ineffective or downright harmful. Bone marrow transplants for metastatic breast cancer, super-radical mastectomies for breast cancer, stenting every artery with any blockage for stable patients with heart disease, the list goes on and on.
Our lab, when confronted with a request for the newest and greatest test, used to go by a quotation of unknown origin:
“Be not the the first by which the new is tried, nor yet the last to lay the old aside.”
However!! Your point about what is communicated to the patients is critical, and no one seems to be addressing it. Are they just being given the new treatment, denied the new treatment, or being given an honest, evidence-based assessment of the knowns and unknowns of this latest research? That, to me, is where this discussion may make a real difference. And I bet you are right – it’s probably sadly deficient.
Paul,
Not necessarily a question of “not paying attention” or “unaware.” Maybe they are just waiting for more proof before they change their practice. Precedent has standing in medicine. Standard of care/practice has standing in medicine. What is “strong” evidence? What may be strong evidence in an experimental, university hospital may not be strong enough evidence out in the hinterlands. Large, experimental academic medical centers have more leeway to experiment with new treatments and protocols than small, rural health clinics. Like everything else, “right” is contextual.
Thanks, Larry and Craig.
So, it is just good enough for some people and not others? How would you explain that to a woman is now reading this who had the surgery at a hospital that either was not aware or chose not to pay attention.
OTOH, if the conclusion is not strong enough scientifically, why have some centers adopted the practice?
Or, are you just saying that this is one of those cases where the judgment lies with the surgeon and oncologist? If so, do we have an assurance than the patients are being presented with a full explanation, pro or con?
It would be interesting to compare what they are telling patients at hospitals that have adopted the new approach versus those that have not. It is clear from the article that the doctors at MSK, for example, are leading their patients in a particular direction. What words do they use to explain that to patients, compared to those used by another hospital that has not yet changed direction?
This would be a great point but as the editor of Oncology Times just told me, the trial results were presented to the cancer world last spring at ASCO and duly reported in, among other places, Oncology Times. So the investigators did make a good faith effort to report and disseminate the results. There’s always the problem of the lag in practice but this does not strike me as an example of unethical behavior.
Paul, I couldn’t agree with you more.
Sadly, in today’s competitive market for patients at medical centers (esp teaching medical centers), it gives an institution an advantage to enhance its reputation as a leader or why it is “always” a leader in utilizing the most recent data, if even for a short time. Collegiality and data-sharing among research sites is becoming a relic of the past in the name of proprietary information and patents.
It’s a shame and, in this case for many women, shameful.
Probably not a case of ethical blinders, nor a case of laziness. Today’s latest, greatest medical breakthrough is often tomorrow’s disaster that “everyone” can see perfectly from hindsight. That is why careful, conservative, and conscientious physicians will change their practice only slowly. Change will only happen after a preponderance of the evidence from many different, independent centers all arriving at similar conclusions after a good interval of time and many different patient populations. Fads exist even in medicine. I have sworn never to be taken in by them.
Non-physicians are the first to be taken in by fads, and the first to push their physicians into accepting them. They are also the first to blame their physicians and sue them once said fads don’t pan out. I have also sworn never to let anyone have a double standard at my expense.
This particular example may or may not be a fad. I will let my general surgeon colleagues sort that one out. Ultimately, time will out.
http://www.youtube.com/watch?v=mH3k-nEP55s Our humorous take on OBAMACARE