The Case for Being a Medical Conservative

Drs Vinay Prasad, John Madrola, Adam Cifu, and Andrew Foy have written a fantastic article about what they call “Medical Conservatism.” Read it HERE

I never thought that those in the movement to prevent overdiagnosis/medicalization and overtreatment would be labeled as “conservative” in our thinking - but I identify directly with many aspect of this article.

I am proud to work with an organization (The Therapeutics Initiative) which does rigorous, unconflicted review of the medical evidence. Many (but not all ) of our conclusions are essentially that the drugs don’t work as well as we wish they did. And for coming to these conclusions, we have been called nihilists.

Like anyone, I want the medications to work, and work well. Yet, I understand that they often do not, and that we need to stop pretending that they might kinda sorta a little, when the evidence says that they (sadly) really don’t make a meaningful different for outcomes that matter to patients. This can be hard to reconcile in clinical practice where clinicians and patients alike get stuck on the hope of success in the face of illness and adversity.

The authors explain there terminology further:

Our choice of the term medical conservative does not imply a political philosophy, although William Buckley Jr.'s definition of conservatism aligns well with our approach to patient care:

“A conservative is someone who stands athwart history, yelling Stop, at a time when no one is inclined to do so, or to have much patience with those who so urge it.1

Here is what we believe:

Medical conservatives are not nihilists. We appreciate progress and laud scientific gains that have transformed once deadly diseases, such as AIDS and many forms of cancer, into manageable chronic conditions. And in public health, we recognize that reducing exposure to tobacco smoke and removal of trans-fats from the food supply have contributed to the secular decline in cardiac event rates.2 Indeed, medical science has made this era a great time to live.

The medical conservative, however, recognizes that many developments promoted as medical advances offer, at best, marginal benefits. We do not ignore value. . . . The medical conservative adopts new therapies when the benefit is clear and the evidence strong and unbiased. 

In the article, they show this graph, comparing the magnitude of benefit for a patient to the cost of the care, with some examples:

gr1_lrg.jpg

The area on the left is where we want to be. The “A” items make a really really big differnce for people’s well being. Not surprisingly, a lot of the modifiable social determinants of health live in “A” territory. The trouble is the “C” territory, the things that we do that make basically no impact for patients but that cost an extraordinary amount in terms of harms, burden, and financial measures for patients and society.

My colleague Juan Gérvas said it well when he wrote our ‘preventing overdiagnosis’ mailing list: “the end of the curve is not flat, but going down... [at that point, the] harms outweigh benefits.; on the end of the flat part of the curve, additional spending, whether it be on a new drug, device or diagnostic test, confers more harms than benefits to individual patients or society".

The answer to everything wrong in health care

TOP Alberta has released a beautiful infographic Evidence Summary: The Benefits of Continuity in Primary Care, and the document also serves as an overview of the 112 publications they reviewed.

It speaks for itself. Maybe the title of this post is a bit grandiose, but as a shameful hypocrite [I have very little continuity in my clinical practice, something I'm working to remedy] I cannot underscore how important this idea is.

Every physician, nurse, administrator (yes, you!), health policy person, and their uncle needs to not only know this but act on it. Continuity is what we need.

It's not a fad. It's something that we used to have. And it has slowly been eroded, without too many people noticing, as we kept focussing on the newest technology and the latest pharmaceuticals as if they would solve everything.

In BC, the essential nature of continuity has been recognized particularly with the work of Marcus Hollander and was implemented in the GP for Me/Attachment Initiative. Unfortunately (some might dispute this), changing physician incentives to try to encourage more attachment hasn't made much of a difference for patients. So while we know that we need continuity, we don't know how to 'make' the system or the providers do it.

It's a perfect storm for patients: Can't find a GP, or if you can it's hard to build a relationship with them because they are so busy/unavailable/don't have enough time to spend with you; the GP doesn't know all the details of your care as pharmacists/naturopaths and others expand their scope and don't communicate with the GP; the medical records at the hospital or from the specialist in the other city don't link with those of the GP so no one knows what is going on; when a referral or requisition is sent, there is no confirmation that is was received so it might be that you are just waiting, or it might be that it has been lost and you will never hear back about the appointment; when a home care support worker or nurse comes, it is a different person each day and they don't know you or your needs, and they aren't allowed to do the things you need help with most.

Health care really is about caring for people, and how can we do this when we do not build robust and lasting relationships?

The review did not cover provider satisfaction but personally and in BC studies so far, physician satisfaction is improved by continuity with patients. However, this is not how most young graduates are practicing; Yet another great reason that we need to look more into this.

Is it too good to be true? Before we rush ahead and try to force the "magic pill" of continuity, we need to know more about why it's being eroded, and if we can save it, then how?

 

Source: http://www.topalbertadoctors.org/file/top-...