Tuesday, 17 Sep 2019

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What Happened to Science in Medicine?

I tell my patients there are three types of science:

  1. “Investigative science”, which sometimes gets it right.
  2. Science in the courtroom, which is “junk science”.
  3. Science in Washington, DC, which is “political science”.

Our decisions are based on art and science, our patient’s medications are brought to market based on science. And yet, the way we are extorted to treat and mandated to care for our patients is not based on any science. It is political science.

We need to make Medicine great again.  What is happening? Here are a few examples.

Prior Approval versus the Compendium of Medications

We write a FDA approved medication prescription for our patient for a specific medical condition and then we are told by the patient’s insurance company that we cannot use that medication but we need to use another FDA-approved medication in the compendium, which does not have an FDA label indication for the medical condition we want to use it for. This medication is not what we want to use but otherwise we cannot treat our patient. BUT then they turn the tables around when we want to use an FDA-approved medication supported by literature to work for a condition not listed on the approved label, and then have it declined based on the package insert (right drug, wrong disease)! In these examples, science does not trump politics, or economics. This is done by insurance companies and is called non-Medical switching. It’s not based on medical science but insurance pseudo-science.

Electronic Medical Records 

Electronic records, where the science and scientific method for electronic health records is. This was discussed by Dr. Artie Kavanaugh in RheumNow in May 2015. I agree EMR has great promise. I began using one program “QD” in 1998 for that reason. Slowly it was integrated into my care and fulltime since 2008. QD was developed by physicians including rheumatologists for physicians. It is still great, has the ability of me to personally change the program on the fly at any time to help the care of the patient (you can’t do that with the “big Guys”. This needs to be done centrally and takes a long time). But the typical EMR picture is a physician typing on the computer with his back turned to the patient.

Thus, the imposition of a computer that now takes precedence in the doctor patient relationship. Its time consuming, prolongs patient visits, needs to qualify for “meaningful use” – but has not truly shown a benefit in patient care or cost of care. Dr. Edward J. Schloss writes (Kevin, MD, August 29, 2015) that “heath care documentation is done for three reasons:

  1. health care delivery (that’s the obvious one)
  2. regulatory compliance (checking all the boxes our government and payers think are important)
  3. malpractice avoidance (no one wants to get sued)”

Hence, EHRs are commissioned by administrators for administrators and not focused on patient care, but rather on regulatory compliance. Where is the science to prove this helps healthcare? It is just not there. We see less patients, it is less efficient. The only saving grace I see is electronic prescribing but even that has shortfalls – can’t find the pharmacy, not have all of the medication patient takes, fill out an electronic Prior approval – that even takes longer, so I unfortunately still use paper and faxes for PAs.

We are Being Overtaken by Health Administrators.

Medicine has been taken over by administration which stifles scientific innovation. Science has been lost in this environment. He notes that medicine has been kidnapped by a bunch of government-driven regulations that cost billions of unnecessary taxpayer dollars for oversight. There is no science in this bureaucracy which has exploded out of control. When you have so many excessive regulations that you need that many people overseeing checkboxes for regulatory compliance instead of delivering medical care. Medicine should be to be about the patient-physician relationship and how to apply science to this art.

What about ICD-10? Where is the Science of it?

Steven M. Croft, MD has written a perspective on “The Argument Against ICD-10 Implementation” that is worth reading.

We are told we need ICD-10 to collect better data and improve quality of patient care. It is expected to lead to better justification of medical necessity and improved implementation of national and local coverage determinations. The result will be more accurate payments and fraud detection will be improved.

ICD codes were developed by the World Health Organization for mortality statistics. We are told that every country in the world ICD-10. But for most this is for hospital coding. For us, ICD codes are used for one reason alone — to file claims and get paid and by insurers to deny payment. The U.S. is the only country using ICD codes to pay physicians. ICD-10 codes will result in more claim denials. The cost savings from the ICD-10 conversion is based on paying fewer dollars to providers. As physicians, we should expect both to spend more time coding and to earn less money.
The ICD-10 burden is placed on top of cuts in insurance payments and excessive administrative demands such as Meaningful Use, Physician Quality Reporting System (PQRS), and increasing insurance authorizations. For some physicians, it will be the final straw — forcing some to close their doors and abandon the practice of medicine, leaving thousands of patients without care.

Changes in medicine should include rational, fact driven, common sense approach to change supported by scientific evidence. It should be evidence driven and not public policy driven, unless there is a clear, measureable public health benefit. As physicians we and our patients have the most to lose but we have had the least input. All voices need to be heard before these programs are put into practice. This system of crony capitalism is hurting healthcare and practitioners.

We need to bring science back into medicine and medical decision making.

We hope that the AMA will help lead the charge to real quality. The reports at the AMA interim meeting are encouraging.

We need to make Medicine Great again!

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Doctor Goldman is a former Clinical Professor of Medicine, Emory University School of Medicine, Atlanta, Georgia. He is presently President of Medical Quarters and Chief of Rheumatology St. Joseph’s Hospital, Atlanta, Georgia. He is in solo rheumatology, immunology and osteoporosis practice in Sandy Springs, GA. He has been named a Master of the American College of Rheumatology (MACR), a Fellow of the American College of Physicians (FACP) and a Certified Clinical Densitometrist (CCD).

 

Rheumatologists' Comments

thanks Jack
For the most part still true AMA had the EHR white paper in 2015; but in Chicago, June 2018 At the National Annual meeting said they will study it for 2 years and in National Harbor during the Interim meeting November 2018 - said maybe 2021. They are dragging - not action means no help to all of this. Tom Price had the vision but I suspect was set up and patients and physicians lost him - he understood the process. Steve Stack was a former AMA president and tried to do something but he told me in June 2018 that the AMA is just not ready to do anything. My bottom line is EHR is not scientific and we are scientists and should not be allowing this policy to rape medicine! EHR should be scientifically integrated into medicine and not stuffed down our throats.
Thanks Dr. Goldman. I agree to all points. If there is any merit in EHR that I am not aware of (since I don't use it, and probably don't plan to unless I have to), it's not worth all the cost, time, and headache, especially true for solo practice