Two recent posts by Matthew and Bob Wachter on the crisis in primary care sparked great debates in the comment sections.
Matthew’s inference that Medicare’s bankruptcy will be fast upon us if everyone with brain cancer received an experimental surgery like Sen. Ted Kennedy recently had evoked this response from Bev. M.D.
Kennedy’s case is an excellent example of why evidence-based medicine
will never translate into a "cookbook" of completely standardized
practice. As a pathologist who has looked at this nasty tumor under the
microscope too many times, glioblastoma is almost uniformly fatal
within, at most, a few years. But each patient’s tumor, and each
patient’s age and medical background, and each patient’s will to fight,
is different. Also, many medical advances are made by doctors
courageous enough to defy standard opinion who achieve good results and
then over time develop a track record to make their treatment an
accepted and evidence-based one. Therefore, one cannot apply a uniform
and permanent EBM rubric of – gonna die anyway, don’t operate – to all
glioblastoma patients for MEDICAL reasons. However, one COULD apply it
for social/political/economic reasons, and therein lies the basic
conundrum before us.
Deeper in the comments, Peter wrote:
Bev, I agree to a point, but why should there be only two people
involved in the decision – the doctor, who gets paid when he/she
operates using someone else’s money, and the patient, using someone
else’s money, and therefore has nothing to loose. If we went with this
thinking then who stops all the Mickey Mantle decisions? Is every Terri
Schiavo worth keeping on life support waiting for God to perform a
miracle? Would a Medicaid patient get to go to Duke and obtain the same
try? I know this discussion goes around in circles forever but there
must be a better way if we are going to avoid bankrupting the "system."
