We focused the past four issues on regenerative medicine—a form of “postmodern” medicine likely to change the way many conditions are treated. There is no question that regenerative medicine will become mainstream at some point, but in light of the fact that many aspects of 100+ year-old “modern” medicine have yet to be universally adopted, there is a question about how efficiently individuals in healthcare practice, policy, and financing—and indeed the health system as a whole—will take to postmodern medicine. The relatively few, but long, articles digested for this issue suggest the answer may be: Not very.

Overturning Paradigms

Thomas Kuhn pointed out that discoveries and advances that fail to fit the prevailing scientific paradigm are often strongly resisted by the old guard. William Bestermann, writing last year in the Health Care Blog, believed no better example of this could be found than in the treatment of cardiovascular and arterial disease.

Take the accepted wisdom that heart attacks are caused by a progressive blockage. “Virtually the entirety of the science, practice, and financing are organized around this idea … [and that] If we open that blockage before it becomes complete, we will save the patient.” This paradigm holds sway even today, despite a surprise finding in 1988 that coronary angiography cannot, in fact, predict the site of a future coronary occlusion. The finding meant that “coronary bypass surgery or angioplasty … would not have been effective in preventing the majority of infarctions…instead effective therapy to prevent myocardial infarction may need to be directed at the entire coronary tree…”

Within seven years, four more studies came to the same conclusion, finding further that “plaque disruption with superimposed thrombosis (obstructive clot) is the main cause of the acute coronary syndromes of unstable angina, myocardial infarction, and sudden death.”

By 1995, it was well established that while bypass surgery or stenting provide “rational and often effective therapies” for “fixed, high-grade stenoses (blockages) . . . these treatments do not address the non-stenotic but vulnerable plaque (which may rupture and suddenly block the artery with clot)… [and that] To reduce the risk of acute myocardial infarction, one must stabilize lesions to prevent this disruptions, particularly the less stenotic plaque.”

Even though we can now “dramatically stabilize plaque and reduce plaque progression by smoking cessation and reduction of cholesterol, triglycerides, blood pressure, and blood glucose [and] prevent clot formation with aspirin and other medications,” the practice paradigm—bypass or stents—persists as if the science had never changed. Bypass and stents remain the practice in far too many instances.

One expert opined that we would have to wait until current practitioners are replaced by the next generation, before practice will match the scientific paradigm; or, we might say, before evidence-based practice becomes the norm.

Art vs. Science

In a splendid article in the New York Times Magazine (“Making Health Care Better,” November 8, 2009) staff writer and economics columnist David Leonhardt discusses the difference between medicine as art and medicine as science and why that difference continues to comprise an obstacle to a better healthcare system. Here follows a brief summary, as we interpret him.

For most of human history doctors did more harm than good. Yet even after scientific theories about germs and viruses appeared in the late 19th century, patients continued to go to doctors who put their faith in leeching and other often damaging treatments. “Haltingly and skeptically,” doctors eventually came around and adopted the scientific method. As a result, “diphtheria, mumps, measles and polio were conquered, and pneumonia and heart attacks became far less deadly.”

But the modern transformation is still not complete, because doctors have been unable to handle the “explosion of medical research over the last century [which] has produced a dizzying number of treatments” not just for different ailments but even for the same ailment. Examples: “For someone with heart disease, there is bypass surgery, stenting or simply drugs and behavior changes. For a man with early-stage prostate cancer, there is surgery, radiation, proton-beam therapy or so-called watchful waiting.” All such therapies may have been subject to “randomized trials, statistical-significance tests, the peer-review process of academic journals and the scrutiny of government regulators.”

Thus, the doctor is dumped back in the unscientific world of judgment and intuition. Sometimes, indeed, there is no choice, but the result is that “different doctors frequently end up coming up with different answers to the same question. Cardiologists in Davenport, Iowa, are quick to insert stents; cardiologists in Iowa City and Sioux City are not. They can’t both be right. Some people with heart disease are getting the best treatment, and some are not. The same is true of debilitating back pain, various cancers and even pregnancy.”

Over several decades, Intermountain Health in Colorado has had much success in collecting evidence about the efficacy of various treatments, developing standard protocols to treat those conditions, revising and adjusting the protocols in light of new evidence as it is captured, and getting its doctors to use the protocols. The results: A reduction in the variation in how doctors treat some 50 or so conditions; increasingly refined evidence of what aspects of treatment make a difference; and much better outcomes—such as an increase in the survival rate for ARDS (acute respiratory distress syndrome) patients from 10 percent to 40 percent.

In contrast, it has been found that “many hospitals are not even aware of what they do well and what they don’t,” yet their chairmen think they are above average even where Medicare data suggest they are among the worst in the country. “Not a single one said the hospital was below average.”

Autonomy and Intuition vs. Protocols and Evidence

Doctors have a high degree of professional autonomy, and they rely on intuition. That means they are free to do what they like, and what they like is to act on intuition rather than on protocols imposed on them. But their intuition is often based on only a few, usually recent, experiences. Dr. Jerome Groopman exemplifies this mindset by arguing in his book How Doctors Think that evidence-based medicine is of limited value and that it discourages doctors from exercising their intuition and judgment and from acting on their instincts. (Dr. Charles Shanley and I previously challenged Dr. Groopman’s argument in a 2007 article for Hospitals & Health Networks Online.)

Intuition and empiricism both have roles in medicine. The question is how to balance the two. The highly trained, experienced, and expert mind of a physician should be focused on the problems for which data do not have a ready answer. It has been determined that “the overall record of decision-making approaches that are based mostly on intuition is far weaker than the record of decisions based mostly on data.” Example: In a meta-analysis of “dozens of studies that compared clinical judgments with data-based diagnoses, … clinical judgments were better in only a few instances” and “the data-based diagnoses substantially outperformed human judgment in nearly half of the studies.” Furthermore, “with data collection becoming ever cheaper, … the number of occasions in which an intuitive approach beats a systemic one is getting smaller all the time.”

And still, many doctors ignore evidence. “The clearest example” is the Pronovost checklist of five simple steps intensive-care doctors should take to prevent bacterial infection when inserting an IV line into a patient. “The checklist reduced the infection rate to essentially zero at 108 hospitals in Michigan where it was adopted. [The 108 included, we are proud to note, our own Detroit Medical Center hospitals.] Pronovost published the results in The New England Journal of Medicine in 2006. But most intensive-care doctors are still not using the checklist. To insert an IV line, they continue to rely on their own judgment.”

Doctors are not alone in ignoring the evidence: Patients ignore Medicare data published on the Web comparing hospitals on various measures, like infection rates and surgical-complication rates. They continue instead to place their faith in their doctor’s judgment about where to go for surgery.

Better Care, Lower Revenue

There is no “virtuous cycle of innovation, success, and expansion” in today’s US healthcare system. Few hospitals have adopted the Pronovost checklist and few have followed Intermountain’s lead in standardizing lung care for premature babies (which not only cut the number who went on a ventilator by more than 75 percent but also reduced costs by hundreds of thousands of dollars a year.) There may be a perverse and chilling reason why they do not follow: By reducing the number of babies on ventilators, Intermountain received less money under fee-for-service reimbursement. The message would seem to be: Improve your quality, lower your costs, and lose money!

The same message comes through in the case of home medical monitoring. Several US hospitals that have adopted home intervention programs to reduce ED visits by pediatric asthmatic patients may be losing money as a result. One such program at Children’s Hospital Boston educates families about asthma and its treatments and how to eliminate dust and irritants at home, common causes of repeat ED visits or hospitalizations. The result: Healthier patients who likely will require less medication. A similar program at Woodhull Medical Center in New York resulted in a 52 percent drop in ED visits and a 78 percent decrease in hospitalizations for asthma.

Clearly, there is some revenue loss, but over the longer term the loss could become a gain if beds vacated by asthma patients become filled with patients with more complicated conditions.

Solution: Health Reform

The last word goes to Leonhardt: “As long as doctors and hospitals are paid for each extra test and treatment, they will err on the side of more care and not always better care. No doctor or no single hospital can change that [in the average—it seems to us they could change it for themselves]. It requires action by the government.”

The PPACA (Patient Protection and Affordable Care Act—i.e., health reform) hopefully will constitute sufficient action. With the revolution in postmodern medicine gathering steam and promising so much, it would be costly in both dollars and lives not to dismantle unnecessary barriers to its progress.