From: tas@pegasus.com (Len Howard)
Subject: Re: Bashing, truth, etc.
Followup-To: talk.politics.medicine  
Summary: agreement from the field  
Keywords: clinical judgement, multi-variant analysis, factors  
Organization: Pegasus,  Honolulu
Date: Tue, 22 Dec 92 19:58:44 GMT

In article <BzM7Gs.8sM@mentor.cc.purdue.edu> hrubin@pop.stat.purdue.edu (Herman Rubin) writes:

[prior discussion of folk & scientific medicine deleted]
>
>As to the first issue, I am afraid you misunderstand both what I said and
>also what is involved in "scientific" medicine.  I am putting on my 
>professional hat here.  The problem in any form of inference is that
>of decision making under uncertainty.  Now this problem, even simplified
>to the standpoint of a self-consistent person with infinite computing power,
>has only been reasonably treated in this century, and from the most general
>statement of the problem, I am credited with the first general result (1948).
>But even in the last century, the idea that a simplified model could be
>CORRECT, as distinct for APPROPRIATE FOR USE, came to be recognized.  It
>is never the case that the proposed action has NO effect, so that the usual
>testing is just plain wrong.  And in the cases in the biological, social,
>and psychological sciences, where the accuracy of the simplified theory is
>much worse than that of the data, this problem gets very difficult, and 
>even relatively simple problems show unexpected complications.  
[effect of Vit C deleted to save space. Main point follows] >
>individuals, how does it interact with other things, etc.  The problem is
>not an easy one which can be handled with a simple statistical package.
>In addition, in quite reasonable problems, such as can be encountered in
>everyday medical practice, the resolution of the problems with the available
>information may involve computations, the results of which can be very much
>counterintuitive.
>
>We must use methods appropriate to the information available, not just
>those appropriate to the simpler problems of physics and chemistry.  And,
>in addition, we must take into account that "one man's meat is another 
>man's poison", and that individual preferences, even for supposedly 
>identical individuals, differ enough to affect the appropriate action.

Dr Ruben, I would like to in a sense agree with your thesis but in
addition expand a bit on the decision making process I see in my own
practice of medicine.  After reading your post, I tried to analyze how
I make the treatment decision in a particular case. To wit...
    The decision to recommend one particular course of treatment has
several variables:
a. The underlying medical education of the physician.  What sort of
philosophical base is present.  What was the thrust of the education
provided by the particular medical school, i.e. was it pragmatic,
developing general practitioners, or was it theoretical, intending to
produce research physicians?  How many years ago was the physician in
medical school?

b. Does the physician keep up with the medical literature?  No one
person can accumulate enough experience to personally have treated
enough patients in many uncommon conditions in order to develop a
significant sample to make a valid treatment recommendation.  "Fad
treatments" are the result of depending on one's own limited
experience.  Using the medical literature, while recognizing the bias
of the submitter, will enable the physician to make a decision based
on a large enough sample to have some validity.

c.  What is the experience of the physician.  Medicine changes rapidly
in the last 40 years, and many physician new to the practice have
never done some of the procedures that were common in the 50s, and
still provide advantages today.  Likewise, there are many new
procedures that require the older physician to keep up with current
methodology and learn the new techniques as they achieve validity.

d.  What is the mode of practice of the physician?  Is he one who is
quick to jump to the newest treatment, or one who will stick with
proven methods until a significant amount of experience is published
in the literature.  Is the physician practicing in a large group,
where the consensual mode is the way of all, or in private practice
where the individual is free to follow his own dictates without
constraint.

e.  Finally, what is the patient like?  There is a quantum difference
between discussing treatment options with a professor of Biochemistry
at the local medical school and a young unmarried woman who dropped
out of high school because she got pregnant at age 16.  In the former,
as position of collegiality may be productive, while in the latter a
paternalistic, benevolent attitude may be the only option.  And what
is her response to the information provided?  Is it necessary to couch
counseling in non-threatening terms to a person who is skittish, or
can one go into all the options with a calm, thoughtful mature
individual?

The sum total of all these factors, I believe, goes into making up
what we call clinical judgement, and what you, I think, refered to as
intuitive decision making.  I submit that trying to enter all these
factors into a statistical program may produce a decision which may
appear globally correct, but may in fact not be the best decision for
that particular patient.  There is a non-quantifiable sensitivity to
the patient that the experienced physician develops over the years
that takes a part in each medical decision.  I really don't think this
can be programmed into any objective decision-making program, but you
are the expert in that field <g>.
>
>I agree fully with your last thr [sorry for screwing up the format] er
ee sentences, but I have yet to encounter
>a physician who does this.  I suspect that even those who try fail because
>of their lack of familiarity with the range of possible actions, of which
>much must be laid to the medical school training, and the training of
>interns and residents.

This is the place where how the decision is made depends on all the
factors I enumerated.  I think we can go too far in invilving the
patient in the final decision.  By this I mean that I see some younger
physicians today unwilling to make a medical recommendation, rather
presenting the options and letting the patient choose the course.  I
think this is just as wrong as not telling the patient anything and
making your own decision total for them.  The patient, unless trained
as a physician, with experience and background equal to your own, can
only express a preference as to how she perceives what you tell her.
The physician who makes no recommendation is copping out on his
responsibility as a professional.  If I were attemting to set up a
sampling method to analyze patient's behavior impacting on results of
medical treatment, and came to you in consultation, I would expect you
to make a recommendation.  If all you did was try to teach me some
principles of statistical analysis and tell me to make my own
decision, I would feel you had not helped me much.  I would want your
recommendation as to how I should set up my model.  That's what I come
to you for, to benifit from your expertise and experience.
>
[discussion of chiropactors et al deleted] >
>
>This is a consequence of the anti-insurance procedures.  I know of no other
>area where anything called insurance covers normal costs, and almost ignores
>extraordinary situations.  Prepaid medical care, whatever it is called, is
>a socialist conspiracy.

Well, I must part company here, Professor.  For the past 17 years I
have practiced in a closed panel HMO.  We have been on the cutting
edge of effective delivery of medical care.  Our group did the
original work on the Primary Care Provider system that is now in use
throughout the entire country.  We initiated Quality of Service
surveys of our patients over 10 years ago, and are rated by a national
survey agency as the top region in patient satisfaction, using phone
and post encounter surveys by an independent agency.  We have 100%
concurrent Utilization review.  We have total Quality of Care analysis
after discharge.  We also have the lowest C/Section rate in the State,
and the lowest perinatal mortality rate in the State.  We can deliver
care to the Medicaid patients at a cost to the State that is 35% lower
than private practice.  Our patients have total freedom to choose
their physician from within our 258 physicians (our OB department has
18 OB docs, twice as many as the town I came from in Michigan, adn the
patient makes her own choice, and can switch if she is not satisfied.)
I fail to see your basis for saying our practice is a "socialist
conspiracy", Professor.  Would you care to elucidate? 
>
[mention of rationing of care deleted]
>
>You have now explicitly stated the conspiracy again.  Together with laws
>against "practicing medicine without a license" and laws restricting the
>availability of chemicals (the FDA wants to ban substances solely because
>their medical effectiveness has not been "proven"); I doubt that anyone
>reading this group will live long enough to find out whether, for example,
>the doses of vitamin E now recommended by many reputable physicians are
>particularly effective, and unless we are going to do massive experiments
>on slave populations, whether they have dangerous side effects.
>-- 
>Herman Rubin, Dept. of Statistics, Purdue Univ., West Lafayette IN47907-1399

Dr Rubin, {please excuse my misspelling of your name at the start....I
am doing this online and could not see it at the time} I again ask you
to explain your 'conspiracy' charge.  The cost of medical care is
expanding exponentially as time passes.  We can spend the entire GNP
on medical care if desired.  There comes a point where the money spent
on medical care must be evaluated for effectivness.  This will involve
decisions about what treatments are going to be paid for by the
general funds (read third party payor) and which treatments will be
excluded from the basic medical care program.  You may call it
"allocation of scarce medical resources" or "basic medical care
entitlement" or whatever PC name you wish to give it, but it is still
rationing, and I don't see any socialist conspiracy at all.  Any
person is free to pay privately for whatever care he wishes to
receive, but the care paid for by third parties MUST be limited in
some ways.

Leonard Howard, MD, Kaiser-Permanente Medical Care Plan of Hawaii.
Department of Obstetrics and Gynecology.

The opinions stated above represent my personal opinions only.  I do
not speack for KPHCP of Hawaii in any way.


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