Monday, April 09, 2012

Can experts really answer all our health questions?

Drs.Pamela Hartzband and Jerome Groopman offer their views on the advice of health care experts, the too often discordant answers to health care questions and the role of "mind sets" or subjectivity on what is portrayed by some as scientific and objective answers.

See here for their comments in the WSJ Lifestyle section on line corresponding to versions of the column appeared in some of the print versions of the print WSJ on 3/31/2012. The title is "Rise of Medical Expertocracy"

The authors suggest that voices from both sides of what is usually ( and inadequately) labelled the political spectrum are claiming that they have the experts to answer all of our health care questions.They question the assumption that there is a right answer for all such questions and that "best practices" as formulated by a panel of experts will be based entirely on a scientific,objective impartial determination.

"For patients and experts alike, there is a subjective core to every medical decision. The truth is,despite many advances, much of medicine still exists in a gray zone where there is not one right answer"

Of course, expert panels use to varying degrees the available data sets, sophisticated statistical methods and epidemiological reasoning, but at the end of the process some one or some group has to make a value judgment.They have to say the risks are or are not worth the benefit.

The authors talk about "mind sets";the maximalists who tend to prefer doing everything or at least a lot and the "doubters" who worry that many (most?) treatments will be worse that the disease.They suggest that experts , as well, have mind sets that will influence the value judgment that they make after their objective analysis. So two experts can look at the same data and reaching opposite conclusions.Patients do this as well.

Since much of medical care is paid for by third parties,the advice of expert panels will likely have a major impact on their policies.

'Patients and doctors can differ with experts and not be ignorant or irrational.Policy makers need to abandon the idea that experts know what is best.In medical care, the "right" clinical decisions turn out to be those that are based on a patient's goals and values."

Amen, but that flies in the face of the over arching principal of the progressive medical mind set which is "Medicine is too important and too complicated to be left to the individual patient with advice from her patient".

My mind set or "priors" tends to warmly resonate with these views of Drs. Hartzband and Groopman and bristles when faced with the lamentations of some of the experts who accuse those whose advice differs from theirs as being ignorant of statistical concepts and seem themselves to be ignorant of the fact that their mind sets may influence their conclusions and advice.

Dr. Viriginia Moyer was the Chair of the U.S. Preventive Services Task Force at the time of the release of their recommendations regarding PSA screening for prostate cancedr. In her editorial in the Annals of Internal Medicine ( 6 March 2012,Vol 156,number 5, pg 392-393) she offers a dissection of the reasons why there is opposition to the Task Force's recommendation which advised against PSA screening.

While she mentions the possibility of some financial interests-both from companies and physicians whose daily work is to diagnose and treat certain screened-for conditions- playing a role in promotion of screening,her principal explanation is "physician Innumeracy". Simply put-those opposing the USPTF's PSA position just don't understand statistics. She also neglects to mention the possibility of financial interests ( third party payers) opposing screening. The Mafia rule of"follow the money" might just apply to both sides of that disagreement.

Dr. Moyer does not seem to recognize-or at least does not mention- the possibility that experts who know their way around NNTs (number needed to treat) and other statistical metrics and techniques as well or better than she might just look at the same data and reach a different value judgment. In fact they do and have even in regard to the issue of PSA screening.

Drs Hartzband and Groopman speak of a new form of paternalism "based on the assumption that Americans are not receiving "quality medical care".

" A lucrative industry has grown up to generate ever more medical metrics,to give report cards to doctors and hospitals, and to base payments on compliance with the "best practices".Yet beyond safety protocols, there is scant evidence that such measures improve our health"