Over at DB’s Medical Rants Robert has responded  to my gentle chiding and has written a nice piece regarding what’s wrong (in his view) with Wampum’s piece on malpractice.  (Note that he got up at 4 am to write it too! Who’d be an intensive internist?)

He’s also alerted me (and you) to a very interesting report about how doctors changed their behavior after the results of the two big trials on HRT and Alpha Blockers in the last couple of years. (Reuters release here but both full articles are unusually available for free from JAMA via my earlier links). The findings suggest that doctors do indeed respond in their prescribing habits to the latest evidence, particularly if the results of the trial are blared all over the press. This just makes the whole conversation over evidence based medicine more and more confusing.  How come doctors change practice on a dime over the HRT study but take years and years to apply some of the best practices elsewhere . . . . . I think Robert’s deliberately trying to make my future article about this harder to write!

The IOM just held a two day meeting to follow up on the 2001 report on Crossing the Chasm, which focused on the quality of chronic care management. This meeting focused on how to make real improvements in the areas of Asthma, Depression, Diabetes, Heart Failure and Pain Control. (I presume that no one from the DEA was there to discuss how locking up doctors improves pain control). Don Berwick was there and gave what sounds a pretty raucous speech about how we’re wasting our money in the health system.  If you haven’t read his speech called Escape Fire, then take a few minutes and do so.

Stephen Schoenbaum and Randall Bobjerg, from the Commonwealth Fund and the Urban Institute respectively, probably just got themselves crossed off the AMA’s Christmas card list by publishing  this article in the Annals of Internal Medicine.  They suggest that doctors are paying too much attention to malpractice and not enough to actually improving patient safety.  In case you missed the point, Schoenbaum, an ex-Exec at Harvard Community Health Plan, one of the "good guys" HMOs is quoted in this interview as saying "All the discussion is about how do we minimize the impact of the suits rather than how do we minimize the number of suits". He also points out that certain groups of physicians, notably anesthesiologists,  have improved their patient safety activities over time leading to the question of why other specialists have not.

I’m going to waffle as to whether greater efforts by specialists to improve patient safety would be immediately effective, given my fuzzy position on whether evidence based medicine is easily-attainable in the real world (see yesterday’s post on appendectomy failure rates).  But it is fair to say that if some of the energy physicians spend on malpractice reform was redirected towards patient safety issues, we’d all be better off.

I am determined to get back to the conversation on evidence based medicine that I was having with Robert Cantor over at Medical Rants before the holidays. Sadly I’m too gummed up with other work to finish the thoughtful response his last reply to me deserves–although I have subsequently interviewed Michael Millenson, the bete noir of the EBM-deniers (if that’s a term!), who’s last piece The Silence took a pretty hard line with the IOM for not being as aggressive as it should be on the topic.  More to come on that later.

But I remind you that I started this by discussing why evidence-based medicine was so hard to achieve in real world  practice.  This balanced article from the Boston Globe shows that big city hospitals which do lots of procedures on kids do better on reducing the false positive rate for pediatric appendectomies than lower volume hospitals. It seems that it’s pretty hard to get the mistake rate of the big city med centers (still up at around 4.8%) at the local hospital where they don’t see so many and have twice the error rate. The key point in the Pediatrics abstract that’s not in the write up for the lay reader is that two thirds of these pediatric appendectomies are done at the lower volume hospitals, and therefore have the worse results. Yet how many parents want to drive an extra hour or so to a distant hospital when their child is in pain? Does the "centers of excellence" concept make sense for this relatively trivial level of surgery? Is an 8% error level acceptable when the cost is more likely to be financial than medical?  It’s still a tough subject. 

I shall vent later mostly about information use, and this study provides useful information on how we should be tackling this type of procedure.  But it’s a bigger system change to move this type of surgery than to get all the transplants, say,  to high-volume physicians.