walkitout (walkitout) wrote,
walkitout
walkitout

_Clinical Decision Making_, David M. Eddy

Subtitled: From Theory to Practice: A Collection of Essays from the Journal of the American Medical Association

Back on June 23rd, I posted about several things, including what a really good book about decision theory should explain.

http://walkitout.livejournal.com/2008/06/23/

This does not meet my criteria for what a really good book about decision theory should explain. However, it's still worth putting a substantial amount of time and energy into, and has a lot to reward a reader, whether they are in the medical industry or not.

Each chapter is a previously published essay (footnotes explain what, if anything, was changed for this publication; usually it's pretty minor things like the exact title and possibly a term-of-art changed between original publication and this book) on the subject of cost, benefits, harms, medical practice, what is being done, why we can't continue to do things this way indefinitely, what doctors should do instead, and what non-doctors will do to doctors if doctors don't take effective action for themselves. Pronto.

There are a number of basic assumptions built into Eddy's View of the World, and they are at odds with a lot of my View of the World. Like, he thinks people should be rational when deciding how to Live Their Life (or Die Their Death). He never/only rarely and indirectly allows for the possibility that common medical practices do far more harm than good -- so his worst case scenario is no-benefit, whereas mine is way-more-harm-than-if-you-dealt-with-your-thing-yourself. This is why Eddy, at least for a while, practiced medicine, whereas I contemplate the appeal of Christian Science at irregular intervals. He also seems to really believe that medicine in the past had a good grasp of what was worth doing and what wasn't; anyone with a decent grasp of any given time-and-place in history knows that this hasn't ever been true in the past. A reasonable corollary is that it is not true now. And _that_ is part of the appeal of Eddy. He basically thinks we don't know what the hell we're doing in medicine right now AND we're throwing crazy amounts of money at it and THAT is not sustainable. He tackles how to carve away at the (growth of) costs while improving quality.

The essays are from the 1980s and 1990s, so they span Oregon's proposal (but not its actual implementation after the Feds said, um, you _do_ know about the ADA, right? And this whole priority scheme you've devised which aims first and foremost at a return to full health/ability is a violation of the ADA. So fix it.) and the Clinton administrations proposal. Eddy consulted for Kaiser Permanente (so we can guess right there I'm biased in Eddy's favor) and helped them devise practice guidelines. During the 1980s, Eddy's perspective was, dude, there's a lot of unjustifiable variation (cf Wennberg) so we need Research and we need Guidelines and computers and math are probably quite necessary. During the 1990s, Eddy morphed a bit, got sucked into the preventive screening thing and got considerably more frantic on the, hey, this is _so_ not sustainable! issue. He also seems to have gotten progressively more suspicious of virtually all specialties, at least when it came to explaining how effective their standard practices were.

Eddy includes a lot of himself in this book. Several essays are imagined conversations with his (deceased) dad -- and you can imagine this could be a big deal for a 4th generation doctor who is working his way slowly around to questioning the entire enterprise of medicine. The concluding chapter is touching (and you know me -- that's not a word I normally go anywhere near) and inspiring, a description of his mother's decline and how the (remaining) family worked together to help her get where she wanted to go. Eddy is a numbers guy, and Eddy has no mortal clue how to translate what he is advocating into language understandable to someone who does things because they feel right or because everyone else is doing them or whatever. He recognizes this, but shies away from coming up with any alternative explanation. If you can't meet Eddy in RationalWorld (with some numbers), you won't meet Eddy anywhere.

Here's the problem with preventive screening of all sorts. You take hundreds of thousands if not millions of _healthy people_ and, based on an imperfect -- often very imperfect -- test, subject them to a series of medical risks and ultimately diagnose some fraction of them as suffering from a disease which if it had caused them to come in with symptoms would be widely recognized as a pretty bad thing (breast or prostate or cervical cancer, say). You treat them (again, risky). The hope is that you caught it before they got sick, and if you do this with enough people, over the population as a whole, the rate of people getting sick and having nasty unpleasant outcomes (death) from that disease will go down. But if it turns out that in the end, the total number of people dead from treatment and disease is equal to the unscreened population due to disease alone unscreened, you spent a lot of money with no gain. And if it turns out that you killed a bunch of asymptomatic people by "treating" them for a "disease" AND you still have the same number of deaths due to disease, you just spent a whole helluva lot of money to kill healthy people. There's a lot of reason to believe that's _exactly_ what we're doing with PSA tests, and we might well be doing it with mammograms for 40-50 year old women, and heck, we might be doing in too many women with pap smears, but that's actualy probably not the case.

And that's not counting the people who survived "treatment" for an asymptomatic disease -- but, say, don't have a dick or a boob or a womb any more. And might really want one. As a for instance.

If we had really amazingly perfect research, maybe we could avoid doing this. Or at least spot it after the fact. But Eddy even does a pretty good job of explaining why this is kinda hard -- not to mention expensive -- to do. He thinks we should do it (so do I); at the time he was writing these articles, he was a bit more optimistic about how that would turn out than I am.

If Eddy ran the world, it would be, on balance, a better place. I think. If a lot of people listened to Eddy, remained skeptical, but adopted heuristics like, when in doubt, don't, the world would be, on balance, a _much_ better place. I don't know how to get us from here to there.

But that does not mean I'm giving up. Somewhere around here, there's a book on public policy. Maybe I'll track it down and read it. After all, I'm almost to the last month of pregnancy, when I focus on how I haven't had the baby yet, am not ruler of the universe yet, haven't ascended yet, etc.
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