McArdle’s essay is about her thyroid, which is on the fritz. Unfortunately, her endocrinologist did not treat her thyroid problems aggressively enough based upon a reliance on outmoded guidelines. This, apparently, means there’s something wrong with evidence-based medicine as currently understood in America.
Please excuse me while I put on my old rantin’ hat.
I assume Megan McArdle is a decent writer when it comes to economics. I will confess to sufficient ignorance on the subject that I don’t know if what she writes is generally sound or not. But this essay is just so painfully poorly thought-out, it should never have been published.
Things start to go south around about here:
As a result, as thyroid patients have now been complaining for years, doctors stopped paying attention to the symptoms. They treated the number instead of the disease. As long as your levels were under 5, they told you that you were fine and there was nothing more they could do.
Changing the guidelines has helped some, but most primary care doctors just target the numbers they learned in school, and older endocrinologists have also often been resistant to change. I know several people whose weight gain was clearly entirely due to their thyroid, but whose doctors stopped well short of a dose that would make them lose the weight; when they pointed out that they still had a lot of symptoms (weight gain, but also the baldness and the fatigue and so forth) they were told that they were just drug-seeking for vanity purposes and they should stop eating twinkies and get their fat asses to the gym.
(Okay, I paraphrase. But that was reportedly the clear implication.)
Really? “Most” primary care doctors do? That’s a pretty broad brush you got there, Megan. Seems to me you’re taking what some people you know said, and leaping to an unsupported conclusion. And I loooooooove that snarky paraphrase, based on the “clear implication” reported to you by someone else. That’s a fantastic basis for criticizing the medical community as a whole!
Let me step back for a moment and concur that doctors should treat their patients, rather than some number on a lab slip. That’s certainly what I was trained to do. In fact, I try to order lab tests only when I think they will help answer a question that my clinical skills can’t on their own. So McArdle is right to be peeved that her first endocrinologist failed to do so. If she’d decided to write about how glad she was to find a new one, I wouldn’t have anything to complain about. But no…
I think about this a lot when people start talking about “evidence based medicine” and how it can help us control health care costs. The question is, “evidence of what?” Evidence based medicine works best on things that are very easy to measure, like blood levels. It is very easy to tell whether a statin reduces blood cholesterol levels. It took a lot longer to tell whether it actually reduced heart attacks.
Um… you know what else is very easy to measure? Thyroid hormone levels!!!!! Which is why, as McArdle notes early in her essay, guidelines for thyroid hormone monitoring were revised downward to better treat patient symptomatology. It’s not that evidence-based medicine failed, it’s that she was seeing a provider who failed to keep up with it.
And the “evidence,” which obviously varies based upon the subject under investigation, is generally some kind of outcome that can be verifiably linked to some kind of intervention. When newer, better evidence comes around, clinical practices sometimes change. Like, say, with regard to the management of thyroid problems as is noted in paragraph five of McArdle’s addle-brained essay, or whether statins should be prescribed. Sadly, “evidence” is not the same thing as “gospel,” which means from time to time it needs to be revisited. If McArdle has a suggestion for a better system, I’m all ears. Perhaps divination?
But this next bit had me attacking my computer with a blunt instrument:
The more we rely on a central board to make decisions for huge numbers of people, the more tempted we are going to be to rely on metrics which can be collected, aggregated, and mined for data. Where does that leave the thyroid patient with “normal” blood levels . . . and a collection of vague, frustrating–but nonetheless very real–symptoms?
Oh, I know. That central medical decision-making board is awful. Whenever I get a new directive from Dr. Strawman, it makes my blood just boil.
I apologize for the following unavoidable use of the caps lock key — THERE IS NO CENTRAL BOARD THAT MAKES DECISIONS FOR HUGE NUMBERS OF PEOPLE, NOR AM I AWARE THAT ANY SUCH BOARD HAS BEEN PROPOSED BY ANYONE. Yes, there are bodies within the scientific medical community that every now and then issue new guidelines for management or screening for various illnesses. Not infrequently their recommendations are controversial, and it takes some time for the broader medical community to reach a consensus. This controversy often stems from physicians’ clinical experience, which may not seem to square with the newer evidence at hand. These guidelines are nothing more than that, and individual providers are free to practice how they see fit.
Now, obviously the government (which I infer is the boogeyman responsible for this ominous “central board”) sets guidelines for what it is willing to pay for through Medicare reimbursements, based upon the best evidence currently available. Again, I’d love to know that system McArdle thinks would be a fit replacement. You know who else does this? Private insurance companies. While it’s nice to have congruity between what I’ve prescribed and what insurers will pay for (government or otherwise), the former is not necessarily dictated by the latter.
I honestly have no idea what point McArdle thinks she’s making with this sloppy, sloppy piece. Her symptoms weren’t well-c0ntrolled, but her endocrinologist didn’t pay attention to her complaints. She found a new one, who is taking better care of her. Hurrah! What this has to do with evidence-based medicine is completely beyond me. I hope she’s better on economics than she is on healthcare policy.
Update: I’d like to begin by thanking Megan McArdle for taking the time to comment at such length in response to this post, which I think demonstrates a great deal of graciousness and class, particularly when considering the tone I took. As I say in the comments, I now wish I had used more temperate language. In the future I’ll try to keep this experience in mind when I choose my language in describing what other writers have said.
From what I understand after reading her comments, her main concern is that evidence-based medicine will be used as a rigid set of rules for determining how medicine should be practiced, and what services will be reimbursed. I certainly agree that EBM works best as a starting-point for medical decision-making with plenty of room for well-reasoned deviation, and should not be used as a strict metric for setting regulations. I would hope that anyone crafting healthcare policy would treat it this way, and I am more optimistic than she that the ACA will do so. However, after having seen how EBM has been used to deny patients of mine treatments that were recommended and appropriate for them, I can understand her concern.