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Rapid Responses: Rapid Responses published:
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Reacting to variations in healthcare delivery
- Tom E Love (25 October 2002)
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Evidence-based medicine in teaching hospitals
- David N Griffith (18 November 2002)
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Arrogance
- Cary R Chrisman (3 June 2003)
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Tom E Love, Lecturer Department of General Practice, Wellington School of Medicine, PO Box 7343, Wellington, New Zealand
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Professor Wennberg has delivered yet another call to the academic and health policy communities about the challenges posed by healthcare variation.(1) In general terms one cannot disagree that variations in healthcare delivery raise issues of equity and appropriateness of care. However there is also room for a note of caution about Wennberg’s strongly stated position. Wennberg is concerned that even after nearly 100 years of academic medicine much practice is still empirically based, and he implies that this represents a failure of academic medicine. But randomised controlled trials are somewhat less than fifty years old: perhaps ‘evaluative clinical sciences’ are a more recent innovation than he suggests. Moreover, there is a growing literature which documents the judgement aspects of medical practice. For example, Tanenbaum gives a particularly clear account of the distinction between professional knowledge and probabilistic knowledge, and the problems of applying evidence based rules to decisions which are essentially the domain of professional judgement.(2) Evaluative clinical sciences do have the potential to improve quality of care, but findings should not be implemented in a black and white fashion which also eliminates the benefits of freely exercised professional judgement. Although there is a very large literature which documents variation, it is sometimes open to criticism. Not all studies are careful to take random effects into account, and these can sometimes be surprisingly large. Claims about the inappropriateness of variability where the comparison is an intuitive expectation that rates should not vary across areas must be treated with close scrutiny. It is also worth noting that, while Wennberg shows that variation can be associated with poor quality care, other researchers have reached more cautious conclusions on this issue. Casparie has reviewed a number of studies which examine the link between variability and inappropriate care, concluding that the link is unproven.(3) Healthcare variation is often intuitively surprising, and raises questions about equity and appropriateness of care. But intuitive surprise is not enough to justify wholesale change to clinical practice. Wennberg is right to call for research and an informed response to the phenomenon, but I would argue that the challenges posed by variation are less clear cut than they appear in Wennberg’s account, and that the risks of misapplying the ‘evaluative clinical sciences’ to clinical judgement argue for a more cautious approach. I do not have a competing interest (1) Wennberg JE. Unwarranted variations in healthcare delivery: implications for academic health centres BMJ 2002;325:961-4 (2) Tanenbaum SJ. Evidence and expertise: the challenge of the outcomes movement to medical professionalism Academic Medicine 1999;74(7):757-63 (3) Casparie AF. The ambiguous relationship between practice variation and appropriateness of care: an agenda for further research Health Policy 1996;35(3):247-65 |
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David N Griffith, Consultant Physician - Care of Older People Mayday Healthcare NHS Trust, London Road, Croydon, Surrey CR7 7YE
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Reading Wennberg’s article about the difficulties of introducing evidence-based medicine into clinical practice I noted the phrase “even the best academic centres (teaching hospitals) …”1 This reminded me of a previous BMJ article exploring the same territory. Paterson-Brown and colleagues reported one reply in response to their survey on whether clinicians were interested in updated reviews of effective care.2 “We are a teaching hospital so we do not need to know what everyone else does.” 1 Wennberg J E. Unwarranted variations in healthcare delivery: implications for academic medical centres. BMJ 2002; 325: 961-4 (26 October). 2 Paterson- Brown S, Wyatt J C and Fisk N M. Are clinicians interested in up to date reviews of effective care? BMJ 1993; 307: 1464. David Griffith
Competing interests: None declared |
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Cary R Chrisman, Clinical Pharmacist Methodist Medical Center 990 Oak Ridge Turnpike, Oak Ridge TN 37830
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In my opinion, one of the primary barriers to the implementation of evidence based guidelines (thereby narrowing the gap in healthcare delivery), which has been hinted at in another response, is the incredible degree of arrogance possessed by not a few of my physician colleagues. Expert knowledge/clinical guidelines have been distilled for many diseases and are disseminated through a variety of mediums, only to be shrugged off by many physicians. When attempting to have some physicians follow expert, evidence based pharmacotherapy guidelines for a given disease, some reply: "I don't need anyone to tell me how to treat my patients" or "I hate cookbook medicine". I'm afraid that we have far too many of the proverbial 800 pound gorillas who do what they want, how they want, when they want. For the present this type of behaviour is tolerated and defended vehemently, although with the looming financial healthcare crisis I believe that the parties paying the bills (insurance/government) will demand that proven therapies be consistently applied. It may take governmental/legal pressure to bring some of us (at least in the United States) to the painful conclusion that, yes, sometimes others do know how to treat patients better than we do. Competing interests: None declared |
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