Sunday, May 10, 2009

Resistance to using the best treatment

The NYTimes reports on the battle against the use of the best evidence in health care. Once again it is reported that one of the biggest problems in getting good health care is the resistance of health care providers to changing the voodoo that they do to treatment that actually works.

This article talks about the Agency for Health Care Policy and Research's guidelines on treating lower back pain. (1) Spine surgeons were so upset that it excluded their favorite treatment - surgery - that they tried to kill the agency. As the Times article reports the reason that surgery was not recommended: research didn't show it was effective but it did show that spinal manipulation was effective.

But as Max Planck said: "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it."

The problem is that people have a hard time changing. Most hate change. Personally I thrive on it. Most don't like finding out they were wrong. I used to be like that. I think the change was when I read the first study that suggested that spinal manipulation might be effective for treating some people's symptoms who have spinal stenosis (2)

This paper came out 2 years after I had told a patient who came in with CT showing the stenosis (he'd been symptomatic for ~10 years) that I couldn't help him and he should have the surgery he had scheduled. The study isn't what I'd call compelling evidence of clinical effectiveness of spinal manipulation but IF it had been published two years earlier I could have told this man he might have a 36% chance of getting better after two weeks of care. Given the fact he'd lived with the pain for 10 years he might have been willing to try two weeks of care instead of "going under the knife". For a while I beat myself up over this and then I realized, you can't know what isn't known. That liberated me to be comfortable with saying that was wrong. As W.V. Quine and J. S. Ullian wrote in The Web of Belief (Random House, New York, 2nd edition, 1978, p. 133) my favorite quote:
The desire to be right and the desire to have been right are two desires, and the sooner we separate them the better off we are. The desire to be right is the thirst for truth. On all accounts, both practical and theoretical, there is nothing but good to be said for it. The desire to have been right, on the other hand, is the pride that goeth before a fall. It stands in the way of our seeing we were wrong, and thus blocks the progress of our knowledge.
The Times article suggests that most doctors are more interested in having been right, rather than being right.

  1. Bigos S, Bowyer R, Braen R, et al. Acute Low Back Problems in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1994.
  2. Kirkaldy-Willis WH, Cassidy JD. Spinal manipulation in the treatment of low-back pain. Can Fam Phys. 1985;31:535-40.

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