Excellent points. As I mentioned in my blog, reading your book left me with a unsettling sense of anger toward a bunch of things – none of which I could put my finger on.

The cliched phrase that “Medicine is both an Art and a Science” is probably a little more true that we would all like. The fact that we don’t have good evidence for most of what we do, coupled with the fact that medicine remains far too anectdotal and too much of an apprenticeship are further validation to the point you make: Data must drive discovery. If we don’t have evidence, what are we doing about it to get the evidence we so desparately need.

You appropriately direct your sights on the multitude of perverse incentives within the venerated house of medicine – poor training on evaluating science, too much influence from outside sources, the fame/fortune/arrogance factors that cloud motivations when the “cure” seems so close. Fortunately, much of this is curable, but we have to stop killing patients in the meantime.

I remain hopeful, however, that the work being produced by Shannon, Phillip Longman, Cohn Porter/Teisberg, et al has awakened both the political and populace will to do the “right thing” about our “collective” health care problem. I believe it is going to require major surgical resection of our current payment structure, an alignment of incentives to reward best practices /best outcomes based on best data.

Thanks to Shannon for helping us not only recognize the problem of overtreatment, but in understanding the reasons why. I hope to be a part of the solution to overcoming overtreatment as part of the redefinition of next generation healthcare.

Scott

I’m not surprised that medicine involves experimentation. I’m surprised that in many cases, including bone marrow transplant, physicians fail to understand that experimenting is what they are doing.

And in the case of bone marrow transplant, they were doing it without the benefit of science, which is the only way to know if the results can be believed. If a woman survived her bone marrow transplant and then went on to live for ten more years, was that evidence that the transplant was responsible for a cure? That BMT was superior to standard treatment? Or would that individual have survived ten years with standard therapy?

What surprises, indeed angers me about bone marrow transplant is that many physicians who knew perfectly well they should be randomizing their patients into a proper clinical trial failed to do so. Sometimes they were already convinced by the poor-quality evidence for the treatment’s efficacy, a situation that argues for better scientific training in medical school. Others didn’t randomize patients because they knew the patient would just go down the street and find another doctor to do the transplant. Which says to me they didn’t adequately explain the extremely experimental nature of the treatment.

I don’t throw stones lightly here. Journalists were also very much at fault here. We helped proclaim bone marrow transplant as a “woman’s best hope.” We helped create the illusion that the science was in, and anybody who stood in a woman’s way was sentencing her to death. Neither was true. And in doing so, we helped create one of the great tragedies of medicine, an era that should be put in the history books as a cautionary tale, alongside frontal lobotomy.