Sunday, April 25, 2010

Comparative Effectiveness Research: Follow the Herd or Lead It?

I never took a psychology course in my life. Perhaps, I should have. How was I to know, or even suspect, that years beyond college, I would be the father of 5 kids? In retrospect, I should have been a psych major, so that I could have developed essential parenting skills in negotiating techniques, behavior modification, unflappable self control, brinkmanship, verbal dueling and mind reading. Without a solid psychological foundation, I have been fenced in and cornered by teenagers who know very well that I am shooting blanks. This has not been a fair fight.

Two weeks ago, my daughter and I traveled to the east coast to visit 3 institutions of higher learning. This is the 3rd child that I have done college visits with. By now, I could give these ‘info sessions’ myself. They are verbal versions of Mad Libs, where the speaker simply plugs in terms specific to his institution. For example:

“What really makes __________ University so unique, is our (insert superlative adjective) professors. In our institution, (select a number between 96-99) % of all courses are taught by full professors. They (insert gushing verb with exaggerating potential) undergraduates! Ou professors would much rather hang out in office hours teaching you Physics 101, then pursuing their (insert adjective that is synomym of boring) research with grad students who worship them. For our profs, teaching trumps tenure. An advantage to having a campus in the middle of nowhere, is that our students can (insert activity that sounds amazingly fun even if it doesn’t exist on campus) every weekend.

The sessions often with remarks suggesting that the college can be anything the applicant desires.

"Our institution combines the advantages of a large research university with a small liberal arts intitutions.  It is both urban and rural.  It strives for collaboration and cooperation, but encourages independent inquiry.  It is both vegan and carnivorous..."
You get the idea.

Like most parents, I want our kids to be exposed to a spectrum of ideology. Even without a psych background, I coyly influenced my daughter’s choices so that we would be visiting 3 colleges that were philosophically distinct.

      College                                Campus Philosophy

Standard Ivy League                           Liberal

Urban Liberal Arts University         Really liberal

Small Liberal Arts Institution           Socialist

After the ‘info session’, the high schoolers and their parents tour the grounds. This is when various campus features are pointed out that will surely determine if that particular college is the right choice. Here are some sample comments that demonstrate the value of the campus tour.

“Here is the chemistry building. This is where we study chemistry.”
“This is a dorm room. Can everyone see the sink?”
“Our library has 14 gazillion volumes. Most colleges of this size only have 11.”
“This is our main cafeteria. I just started giving tours, so I don’t remember what happens here.”
At the beginning of one of these tours, I witnessed a real live psychology experiment in progress. The courteous admissions staff had provided us with umbrellas as rain was likely. Minutes later on the tour, it started to drizzle. It wasn’t real rain yet, but was steady enough to be annoying. Although we were getting wet, no one opened their umbrella. My daughter whispered to me, “Can I open it?” I needed to think quickly as the wrong advice could jeopardize her chances of admission. “Go ahead,” I replied. She complied. Within 30 seconds, every other umbrella popped open. All this crowd needed was for one person to act, so they could all follow. Why didn’t they act at the proper time? Even my daughter wanted my approval before taking bold action.

Folks are comfortable when they are following the herd. I wondered about this observation with regard to the medical profession. How many of our medical actions and decisions are done in imitation of others? How many of our practices are examples of group think and playing follow the leader? Why does medical dogma and practice take so long to modify?

Physicians, including me, perpetuate practices that may be more based on custom and tradition than on sound or changing medical evidence. Here are some examples, most from my own specialty.

  • Physicians continue to support Prostate-Specific Antigen (PSA) testing despite mountains of evidence against this practice.
  • Gastroenterologists perform colonoscopies reflexively to evaluate fecal occult blood, even though this exercise only rarely yields a significant lesion.
  • Cardiologists stent narrowed coronary arteries that should never have been discovered and aren’t responsible for clinical symtoms.
  • Gastroenterologists have been obtaining biopsies from patients with Barrett’s esophagus on a regular basis for decades, even though there is no persuasive evidence supporting this practice.
  • Hepatitis C is treated with toxic medications that don’t work well. They are widely prescribed.
  • Remicade and its cousins have become mainstream treatment in inflammatory bowel disease. My review of the data, even with publication bias, shows rather modest long term benefits, despite risks of opportunistic infections and cancer. The medicine cost a fortune and are often given lifelong.
  • Acute pancreatitis had been treated with bowel rest for decades, until recently.
  • Helicobacter pylori is an enemy of mankind and must be eradicated in our lifetime.
  • Sequential rounds of chemotherapy for incurable diseases are often prescribed because this is a mainstream oncological practice.

Medicine is a great profession, and it can be better. We physicians need to be more skeptical and creative. We should challenge our own clinical practices periodically to verify that they are truly best practices for patients. It is not be enough for us to ‘do what we were trained to do’. For a long time, gallbladders and uteruses were yanked out for reasons that would not survive strict scrutiny. I enthusiastically endorse comparative effectiveness research, although I expect it will be provoke fierce battles from those whose economic survival depend upon the results

It’s easy and comfortable to keep on the same path without deviation. We need folks, however, who will shake it up and make us think, explain and justify what we do. I know that my own practice could stand to be shaken up. Patients can be part of the process by asking us pointed questions, such as, “Doctor, explain exactly why I need this test or medication now?”

There is an undertow that pulls all of us to follow the herd. This is perfectly fine, depending upon the herd’s destination. If it’s headed the wrong way, however, it’s not easy to change a herd’s direction, but it can be done. One person has to stand up when it’s raining and lead the rest of us to drier ground.


  1. I'm curious where you would put St. John's College, Annapolis, MD, in the political spectrum. It's certainly not socialist. It could be considered conservative, except for the emphasis on independent thought.

  2. There is a flip side to this issue:

    I almost never see anyone with severe ulnar deviation deformity because of the effectiveness of biologics as remittance agents. I'm aware of Dr. Sands' studies, and while I agree with him, many of my patients on biologics for Crohns disease seem to do very well.

    On occasion someone I treat for H. pylori experiences marked symptomatic relief.

    Anyone who didn't evaluate a patient with a positive fecal occult blood test would get his hindquarters handed to him in court.

    I won't pass judgment on prescribing successive rounds of increasingly toxic chemotherapy until I'm diagnosed with stage 4 cancer of some sort.

    As far as the political bias of the university, two out of three of my children at the college level went to conservative Christian schools, and one went to a Southern school that welcomed independent thought, as opposed to the high-priced political re-education institutions that dominate the northeast.

  3. Oops. Remittance = remittive.

  4. I think that St. John's College is fantastic. I read through their brochure cover to cover when it arrived a few years back. We had some interesting family discussion about the concept. I congratulate them on breaking the higher education mold. @Bailey, you are spot on regarding fecal occult blood testing. I wouldn't recommend ignoring it in our current legal climate. Gastros like me do colonoscopies on these folks routinely, but the yield for discovering significant lesions is quite low.

  5. Hi Dr. Kirsch, your post is very relevant. I am not a physician but I believe specialty societies should take the lead to develop evidence-based guidelines using comparative-effectiveness research and support it's members who use them.

  6. Michael,
    Terrific post - I share your ambivalence about the herding effect. While there's utility in standards of care and in evidence-based medicine, sometimes there's value in being a step apart, in taking a fresh look at accepted trends.

    As for college tours, I'm with you there too. In the university environment, it would be perfectly horrible if all the kids did all the same things and didn't take initiative or question authority.

  7. Somewhere I read that it takes about 14 years for new data to be completely integrated into practice. This is probably the amount of time it takes for the majority of the docs in practice to be docs that learned that fact in their training.

    We learn what we know in residency, and often practice that way for our entire careers. The docs in academics usually keep up on what is new, as do some docs in private practice. Others just keep going with what they learned i their training.

  8. The part about colleges is right on, though it probably reveals what kind of colleges your daughter was drawn to in the first place. Here in South Carolina there are plenty of dreadfully conservative schools. Heck at one school they don't let men and women walk on the same side of the sidewalk.

  9. Wow! Quite different from what men and women are doing together on many other campuses.

  10. M. Faasse (Chicago)April 28, 2010 at 1:50 PM

    To say there are "mountains of evidence against PSA screening" is simply untrue. Yes, over-treatment of indolent prostate cancer is a big problem, but I think urologists are doing a better and better job of avoiding treatment for low-risk prostate cancer, demonstrating that over-treatment is not screening's fault, per se. Also, I would agree that screening is being used too liberally, especially among patients over 70 (leading to more harm than good).

    However, there has been a 40% reduction in prostate cancer deaths since the early 90's - a mortality benefit that is largely attributable to screening and extends across all age-groups (50+).

  11. According to a Medco study, roughly 50% of doctors are not following 'generally accepted practices' more than a decade after the appropriate academy endorses it.

    Ironically, there are now plenty of commercial data bases that can provide feedback and profiling to a doctor about what they are doing and how they compare to peers. And, unlike college admissions (don't get me started, i put myself thru college partly be giving campus tours at an institution similar to what you outlined above) conformity is desired, if its to the best practices that is.

    You can probably even get your own data, all you have to do is ask the right companies. I can give you the road map

    The irony is that the companies with the data have largely laid low when in comes to docs; they make too much money from selling to pharma and have always been worried about poisoning the well from doctor backlash. However now the momentum is about banning this data - under the red herring of it promotes usage of expensive branded drugs. The real motive is doctors fear Big Brother will force them into cookbook medicine if there is a way to monitor them.

    Both the doctor concern and the need for better practices are valid. Sadly, because everyone is thinking short term, it will all crumble. Or, more likely, the government will fund collection of data (driven off medicare and medicaid rebates and EHRs) that it didn't need to fund if only it would trust the private sector and let the pharma companies pay to fund the data because it makes them more efficient

  12. @RM, thanks for comment. It must be mind boggling the data that the pharm folks have on us. When they come to our office, I know they are aware of my personal prescribing drug history, but they don't like to talk about it. Creepy. Get ready for the government's data that will purport to measure quality, but will wildly miss the mark.

  13. A comment on the topic of PSA testing if I may.

    I was receiving regular treatment by my Urologist for some 10 years for BPH. Exceedingly annoying problem having to urinate every few hours at most, losing sleep at night, unable to fully empty - you know the drill. At the same time I was getting a yearly PSA and digital. Appx 6 years ago my doctor recommended I come in twice yearly because my prostate was enlarging more than previously. Then 2 years ago he said I should have a biopsy - he was concerned about some new symptoms I was having. Within 6 months, my PSA had risen from 4.3 to 7.1. The biopsy confirmed cancer. My age at the time was 61. My doctor carefully explained my options. I could leave it and "wait and see", since he acknowledged prostate cancer is one of the slowest growing types. I could elect to have seeds implanted then, advising of possible side effects; I could elect surgical removal (not advised, but an option, with the almost definite side effects of incontinence, etc.; I could elect radiation - preferably IGRT. I elected to have IGRT - 45 days of radiation, computer controlled placement. 4 months after the treatments my PSA started going down - slowly at first, then faster. A year after treatments my PSA was down to 0.4. Now - 3 years later, it is regularly 0.3 or lower.

  14. Can we add sedating patients with Versed/Midazolam at the earliest possible time and for the most spurious reasons to the list of reflexive (and unecessary and expensive) medical treatments?