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Monday, December 5, 2011

Ranting about continuing medical education, evidence based medicine and cost ignorance

I am attending Harvard Medical School's yearly internal medicine update this week. In a little over 6 days we experience 62 hours of medical education, sitting for 12 hours each day in the conference room of a shiny glass and steel hotel in downtown Boston. We hear world authorities on diseases of all of the major organ systems tell us what they think we ought to know. I am two days into it and still pretty excited, but losing a bit of my enthusiasm.

Most of the presenters follow a set of power point slides, sometimes word for word, that are reproduced in our course syllabus in a size that is nearly entirely unreadable. The form of the talks is to present the scope of the problem, then the recommended testing and treatment, interspersed with the research that is the basis for the recommendations, with an occasional cartoon or anecdote. There are also brief question and answer sessions and cases presented with recommendations on management. There are audience response handsets so we can participate in multiple choice questions, in order to keep us awake and focused.

Each of the presenters is a specialist, the worlds expert on irritable bowel syndrome or sleep apnea or one aspect of liver disease. They teach us how to treat the problems they see as the final go to doctors for the entire world. Some of the diseases are common, but we are encouraged to entertain a differential diagnosis that includes diseases only seen a few hundred times a year. Most of these I have heard of at some time, but could only really say what organ system they involve, not what they look like or how they are treated. We are taught the treatments that studies show work, at least for a proportion of patients. We are taught the 10 blood tests or imaging studies that we should never forget to order if we don't want to miss something. They mention that they realize that we, as general internists, have limited time with each patient, but rarely do they tailor their information to make it practical for us to achieve in a patient visit. They haven't been doing what I love to see clinical teachers do--telling us what they know to be true from their vast experience. I think that the emphasis on "evidence based medicine" has made them doubt the value of their hard won wisdom.

A few of these excellent clinicians have, however, been starting to talk about limitations of population studies to guide therapeutics. One oncologist said that different types of cancer will eventually be seen as collections of "orphan diseases".  Orphan diseases are usually considered to be rare diseases that are well described, but not prevalent enough to warrant as extensive research and treatment development as diseases that are more common and have more of a social impact. What this oncologist meant is that each cancer may have slightly different genetics in different individuals, leading to very different responses to chemotherapies or other treatments.

He gave the example of a new treatment for a cancer that completely melted away bulky metastatic disease in one of his patients, based on a genetic predisposition of the cancer cells in that particular person. I have seen this kind of thing on several occasions. One of my patients is completely free of melanoma nearly 20 years after receiving a cancer vaccine in a trial that failed. The study showed it didn't work. Except that it did, in my patient. She had had a recurrence of her melanoma, in a lymph node, which is nearly universally fatal and pretty much untreatable. It went away and she is alive now with no evidence of disease.

Most of the rest of the researchers have not mentioned, though, the fact that different genetics and maybe environments make this "orphan disease" concept true for other common ailments. We are taught that diabetes is best treated with a certain drug first, then another can be added and so on, but anybody who listens to their patients knows that although it is right to start out with certain guidelines, some patients do terribly with drugs that should work and do great with drugs that are bad. There are drugs that are good for people with heart failure, make them live longer and go to the hospital less, except that in some patients these drugs make them sick or even kill them.  Population studies are just not very good for helping us navigate this kind of water. Anecdotes from colleagues with a wealth of experience are, though.

I am also disappointed, again, as I often am in this sort of situation, but the complete lack of awareness of the cost of the therapies and diagnostics by the clinical teachers. Maybe they are aware, but they don't share that information. In the rare cases where they do share some cost data, the numbers are left in some raw form that doesn't give us useful data as to what cost our patients or their payers will see. A radiologist presented some information on new imaging tests which are stunningly beautiful and potentially very useful. He said that he was aware of how radiological testing was overused, leading to unnecessary and harmful radiation and unsupportable costs, but gave no indication about how that information would be integrated into potential use of his new technologies. An oncologist told us that the cost for a course of chemotherapy for metastatic colon cancer that might give a person 2 more years of life compared to the older chemotherapy cost over $30,000 compared to $60 for the old stuff, but didn't say how many courses a person would get in a year. Letting us know this kind of data should be standard. We want what's best for our patients, but we need this kind of data to help counsel people who shoulder at least part of these costs.

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