Hippocrates

Law (c. 375 BC)

When Lewis Thomas famously dubbed medicine “the youngest science,” he meant not to suggest its immaturity, but rather to celebrate the contributions of fields like biochemistry and molecular genetics to human health. Obviously, advances in the life sciences have produced important innovations in diagnostics, drugs, and medical devices. Ironically enough, however, when it comes to applying the scientific method to determining which treatments and procedures provide the most (and least) benefits, medicine remains in the dark ages. Indeed, according to David Eddy, a cardiac surgeon turned mathematician who coined the term “evidence-based medicine” (EBM), less than 20 percent of what doctors do is supported by hard evidence.

Evidence-based medicine—and its cousin, “comparative effectiveness”—would seem, at first glance, to be common sense. After all, who wants medicine based on mere opinion? If outcomes data confirm a treatment’s benefits, doctors should use it; if it’s harmful, they shouldn’t. And if the data are inconclusive, the effects of the treatment unclear, doctors should be conservative, especially when considering therapies that are expensive or risky. But if we take Eddy’s 20 percent figure seriously, EBM, if it were mandated tomorrow, would exclude most of standard medical practice.

Since the early 1980s, John Wennberg and his colleagues at Dartmouth University have published a stream of research that highlights startling regional variations in American medical practices. Huge deviations occur from state to state and even from one county to another. Geography, in a word, trumps science. Depending on where she lives in Vermont, a woman could face an eight-fold difference in her chances of undergoing a “routine” hysterectomy. As for the chronically ill, Wennberg observes, “the frequency of physician visits, diagnostic testing, and hospitalization and the chances of being admitted to an intensive care unit depend largely on where patients live and the healthcare system they routinely use, independent of the illness they have or its severity.” 

Patients blithely assume that their doctors’ judgments are grounded in science. But Wennberg’s colleague, Elliott Fisher, has demonstrated that people with chronic diseases living in high-cost areas, especially people who get most of their healthcare from top-flight academic medical centers, do not enjoy better outcomes than patients living in low-cost regions. This means that the way physicians manage chronic illness in low-cost regions does not involve withholding valuable care, Fisher concluded, but instead that high-cost systems are inefficient, wasting resources. More healthcare, and higher-priced medicine, does not translate into better health.

Of course, nobody intends to be wasteful and inefficient, or to endanger patients. What limits doctors’ ability to choose the best approach to care, David Eddy told BusinessWeek, “is the human mind.” Many patients suffer ripple effects from multiple disorders. Someone who’s obese and diabetic is also likely to suffer from hypertension, sleep apnea, and depression. Treating any one condition affects the others. Meanwhile, science and technology have exponentially increased what is known and what can be done for each condition. “The practice of medicine, the biology of disease and human variation, are way too complicated for the human mind,” Eddy concluded, “even the mind of a medical expert. And when we try and do it in our heads alone, we make mistakes.”

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