A Conspiracy Of Silence - Part II: Evidence-Based Medicine

We all want to believe that what is being done in our health care world is correct and for the right reasons. It is an issue of trust. For years, there has been a relative reverence for the role of health care providers (physicians in particular) in our community. And we have gone through history believing that health care providers act in our best interests.

If there is one area in which this trust may be betrayed, it is in the health care world.

The conspiracy of silence extends to our health care environment. The “silence” covers a broad scope – from evidence-based practice issues, to self-referral and “referral for profit”, and to over-utilization of services. And yes, these issues exist in virtually all communities in this country.

Let' s start off with the most basic element of health care – that of “evidence-based medicine” (also referred to as “evidence-based practice”). In simple terms, this refers to practice patterns (how patients are actually diagnosed and treated) that are consistent with the scientific literature and/or established clinical guidelines. Why do we care about “evidence”? Because our task as health care providers is quality of care – and science is required to establish what constitutes “effective care”. Clinical practice guidelines don't tell a provider what they can or cannot do - they simply provide the framework for effective clinical practice. We are long past the days of leeches and blood-letting – we now have science to guide us. Without it, long-term health care costs will be higher, and the overall health status of our community will dwindle.

“Evidence-based medicine” is a global issue. There are groups like the Cochrane Collaboration that look at these issues specifically – and provide information that is readily available to all on the web. They critically examine research studies on assessment and treatment procedures by first assessing the quality of the study (related to study design), and then determining if the study provides evidence to support or refute the procedure(s).

Is an assessment process reliable? Is it valid? And is the treatment any better than nature can produce on it's own?

But this whole process starts with peer-reviewed literature – and you'd be amazed at how many "assessment techniques" and “treatment methods” (and I use those terms loosely) that are utilized clinically that have little to no research or evidence to support their use. One example is palpation - using your hands to "assess" the state of tissues. Highly unreliable in the literature - regardless of your experience level. If two people can't agree on what they feel, then how valid can it be? And if it doesn't have a high level of validity, how can it be used diagnostically as a gold standard? As far as treatment methods go, let me give you a couple of examples. I once found that the only information that I could find on a particular treatment method (that is very popular in the active community) was their – patent application. That was it. Nothing else related to the "how" and "why" was available to the consumer. Or another treatment method who's site states that it has "research", but when you read the tab on “research”, none of it is related to the method itself!

Even if there is good research out there, it is oftentimes simply ignored. A perfect example of the issue is the use of ultrasound – which has been researched ad infinitum and found to be … not much better than a placebo (at least in the way it is currently applied). But pick any one of a number of facilities anywhere, and you'll see it being used. Regularly. Amongst doctors, chiropractors, and physical therapists. Now they even market a “home unit”, though I don't think there is a late night infomercial for one – yet.

Over the years, I think I have heard it all – until the next crazy story arises. How about “your leg strength is diminished because you have poor dental alignment”? True story. But many go forward and consider these things as the accepted standard of care – because the empirical evidence is produced by the authorities, the revered ones that we trust. Much like the fitness world, the medical community has continued to use methods that are inconsistent with the scientific literature. And this has become, again, an accepted standard in our community.

Many insurance companies are now utilizing this same information and outcomes data to establish levels of payment for the providers. An example is the work that a group of McKenzie-trained providers are doing in North Carolina. Blue Cross Blue Shield of North Carolina is now reimbursing this group at a higher rate than other physical therapists because their outcomes are better – and they have the data to show this.

When faced with good scientific evidence that contradicts their current practice patterns and methods, most practitioners will simply resort to the "well, I have good results with what I am doing" and “what do you mean, I am not helping the patient” mode and ignore the evidence. This is what makes evidence-based practice so frustrating. “It works” is simply no longer acceptable in the world of health care – because a) the evidence to support or refute the methods exists and can no longer be ignored, and b) finally, the insurance companies are paying those providers that utilize evidence-based strategies to attain better outcomes. Empirical evidence is no longer a treatment standard. But when you bring this up with clinicians, the vitriol flows freely instead of simply moving forward with the evidence we have.

And now, with the news that McKenzie-trained practitioners are actually being paid more in some communities, there are practitioners that claim that “I am trained in McKenzie” when in fact, they are not - or at least no more than what they may (or may not) have learned in school. The McKenzie Institute has a very specific education and examination process that involves intensive study, research, and internship. You must pass an exam to establish a level of competency. I am fully aware of providers in our own community who state that they are “trained in McKenzie” and do not appear on the McKenzie Institutes master list of providers.

You might think that this is all a moot point – that it's not a big deal and that it doesn't effect you. But – it does. Everyone's health care costs go up because of this. Unfortunately, the one most affected is the consumer of their own health care. This is a serious issue of “buyer beware”. Fortunately, the evidence is out there – and readily available to all.

And if that's not enough to make you wonder, then how about we start examining the issues of “self-referral” and “over-utilization of services”? Which, of course, I will do – in the next article.