Those readers who have had an office visit with me know that I like to base our discussions on available scientific literature. Those of you who have visited my facebook page know that I remain cautiously optimistic about the reform of our health care delivery system. However, one of the proposed changes has me slightly concerned. The reforms suggest that all clinical recommendations, and the administrative rules that stem from them, should be based on the information within the body of literature.
The idea of using peer-reviewed double-blinded placebo-controlled studies to guide our decisions is the goal of every physician. It is the widely recognized ideal. The problem lies within the reality of the current state of the medical literature. There are not just gaps in the body of knowledge; there are wide chasms of unknown between the sharp cliffs of fact.
Take for instance, the common problem of blood clots (Deep Vein Thrombosis, aka DVT) after total joint replacement and the rare but potentially fatal secondary problem of those clots migrating to the lungs (pulmonary embolism, aka PE). The April issue of the Journal of Bone and Joint Surgery published the updated American Academy of Orthopaedic Surgeons Clinical Practice Guideline on Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty. This is a document intended to take all the current scientific literature on the topic in consideration and distill it into clear, concise clinical recommendations. Of the 12 recommendations that were generated, only one was rated as “strong”. Based on the literature, the American Academy of Orthopaedic Surgeons could recommend against the routine post-operative screening for DVT’s with an ultrasound test in the absence of symptoms.
Regarding the rest of the recommendations, the literature was found to be either incomplete, contradictory, or sometimes completely absent. I posted a summary of all the recommendations on my Facebook page for your review. DVT’s are common in orthopedic surgery, and the rare PE is devastating. As a result, a great deal of time and effort is directed to their research. Even at that, there are many unknowns.
One of my first lessons in med school stressed the dichotomy of doctoring. It is equal part science and art. It has been true of medicine in the past, remains true, and will remain so well past the end of my career. I celebrate the focus on science in the health care reforms since it a worthy goal and a challenge to the research community. But it needs to be tempered by reality. Treatment guidelines and protocols need to recognize the gaps in the literature. There needs to be awareness that these guidelines and protocols cannot be a substitute for appropriate decision-making, the kind of decision making that doctors work hard to develop during their training and throughout their careers. I am afraid of the consequences of a health care delivery system that loses sight of either the science or the art of medicine.
-Robert J Purchase, MD