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More Than Just Study Data Interventionalists have been performing vertebroplasty for years and some have a long track record of success in relieving many of their patients’ back pain. So when two studies published in The New England Journal of Medicine (NEJM) last October reported the procedure was no better at providing relief than a sham treatment, proponents of the procedure reacted with surprise, disbelief, and some anger. They defended the procedure by attacking aspects of the study that might invalidate the results and thus support their own experience with it. The study results may be greatly affected by what many interventionalists believe: Patient selection is a crucial factor to vertebroplasty success. That just hasn’t been isolated, measured, and proven in well-controlled trials. Scientists tout randomized, double-blind trials as the gold standard of medical research. Clinicians know medical care operates on that gold standard far less than most people think. Science is well controlled in a way that clinical practice just can’t be. Surgeons use the phrase “in my hands” as a euphemism to justify approaching a procedure differently than the way it is described in the textbooks. Most doctors disdain so-called cookbook medicine, believing it reduces them to technicians who simply follow directions rather than doing their own critical thinking. Doctors—like the rest of us—rely heavily on their own experience in making decisions. Interventionalists’ responses to the NEJM studies illustrate that idea. Well-controlled prospective studies provide the best evidence but when such data are not available, physicians still have to make treatment decisions. They make them every day in practice. While more evidence-based medicine will improve healthcare, complete evidence-based medicine is neither possible nor desirable. What do physicians use in the absence of clear evidence or when there is only conflicting evidence? They use their judgment—like a veteran general practitioner guiding the care of an old man he’s taken care of for 20 years. When the U.S. Preventive Services Task Force (USPSTF) released its new mammography recommendations last November, the backlash was furious. The task force concluded that women between the ages of 40 and 50 at normal risk for breast cancer don’t routinely need mammograms; women in that age group should talk with their doctors make the decision whether to have an annual mammogram. That decision proved unacceptable to many in the physician and patient communities, based on different interpretations of data and different experiences. Largely lost in that furor was the idea that the USPSTF position was defendable, though certainly not unassailable. Numerous Western countries—with healthcare systems that compare well the U.S. system—begin mammography screening later than age 40 as in the United States. The healthcare world supports making decisions based on quality data—at least when that data support what a doctor or an organization wants to do in a given situation. In the absence of unassailable data, it is not a coincidence that gastroenterologists tend to focus on the problems of virtual colonoscopy while radiologists tend to see the benefits. Data frequently becomes a shield to defend one’s own views or a sword to attack others’ views. The mammography guidelines furor shows that data and experience are just two factors influencing healthcare decision making. Politics, emotion, and money exert their pull. Politicians are unwilling to be seen as people throwing up a barrier between women and mammography. Anyone with a friend or family member whose life as been saved by early detection is unlikely to care whether mammography is statistically cost-effective. Insurers commonly cite data opposing the value of a procedure (or the lack of data supporting it) to deny covering a procedure. One major concern with the USPSTF mammography guidelines was the fear that insurers would used them as a reason to deny mammography coverage for women in their 40s. Good medical care is driven by more than just data. While it may be the single most important factor, it’s not the only important factor. There is a good reason whiy it’s called the art of medicine. — Jim Knaub is editor of Radiology Today. |
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