"Evidence-Based Medicine" Redefined
by H. Walter Emori, MD
Some years ago here in Medford the administrator of the Medford Providence Medical Center called together all of the rheumatologists in the Rogue Valley for a special meeting. With some anticipation we arrived at her office and were astounded to hear her ask all of us to give up our rheumatology practices and become hospital-employed primary care providers.
Rheumatologists take great pride in training as medical scientists and revel in understanding diseases and clinical manifestations. We are frustrated by non-scientists telling us we need to practice with "evidence-based medicine" when our training tells us that "mechanism-based medicine" is more scientific and reasonable in our patients. We treat the most fragile of our society, most of whom are older and less able to care for themselves. With our training we eagerly anticipate and use innovative treatments for patients who depend upon us for their care.
Health care today promises so many exciting new treatments. In addition to their incredible effectiveness and greater safety, these new treatments are almost always more expensive. Hospital administrators competing for the health care dollars, insurance companies trying to keep down premium cost by restricting expensive treatments, government agencies mandated to monitor or pay for these treatments all try to limit our use. The intense frustration in health care is not diagnosis and treatment. Rather, it is the apparently endless bureaucracy trying to keep us from using treatments we feel are best for our fragile patients.
It is in this context that the Oregon Rheumatology Alliance was founded and is the reason we have flourished. Indeed, ORA has become a model for similar advocacy groups across the nation as rheumatologists fight for their patients. When we can make available better, safer treatment, we feel vindicated by our efforts. When we can reduce the paperwork, we can provide care to more patients while at the same time feel less anger and frustration with the "system."
The future of ORA is assured as long as there are patients who need our specialized care, as long as there is a bureaucracy that tries to tell us how we need to change our diagnostic and treatment methods because health care is too expensive. Each of our patients has confounding, unique factors that limit the usefulness of "evidence-based" treatments. The cost of health care is everyone's business. Can we make a difference in making care more available by reducing costs? Yes, but our mandate is not to provide the cheapest care but rather the most effective and scientific care.
In a society that expects government to provide health care, we as physicians have become agents of the government and those who pay the bills. Our mandate as patient advocates takes a clear determination that we will keep the patient's health benefit clearly in view and that although we will try to influence payers, we will recognize the effort and stress advocacy demands. In a strictly monetary sense, health care is too expensive. If we as a society limit spending, we can bring down financial costs but will most likely increase the human costs in disease, suffering and death. We should be involved in questions related to who pays the health care bills because without restraints, the costs will bankrupt our society or will further harm and disenfranchise vulnerable groups. Our task ahead is not an easy one but is a task with great importance for our patients and our society.