“Evidence Based” Medicine? (7/22/13)
What’s the Evidence?
Modern medicine’s recent mantra is to become “evidence based.” No more listening to anecdote. No more acceptance of poorly performed studies. Now we will look at “hard evidence” and properly designed trials to determine how to best treat human beings.
And for evidence based medicine, death is a “hard” end point. These days many drug studies only observe “risk factors,” not “real endpoints.”
So let’s include death as a real endpoint.
Which is why a recent article by Dr. Lawrence Altman in the New York Times should wake us up – to the false reporting of death.
Not the ultimate outcome, itself. The people in the morgues do not rise up to protest the false attributions of their demise.
Yet death records are used for many purposes, including figuring out what causes death. And the studies Altman cites makes clear that when it comes to apportioning cause, death is not the end – just another, incorrect data point.
Things To Write Up In NY When You’re Dead
The studies were performed in NY, in hospitals of the sort I trained in. Have things changed much?
Not as much as they should.
–Over half of physicians reported knowlingly writing the wrong cause of death.
Why? Drop down menus off electronic records don’t allow correct answers. Which can also be a real problem when you’re writing notes and ordering treatments for living people (but that’s another story.)
–No one told the residents in training how to write up death records. No training at all.
Here, the tradition continues. One example I remember from internship – in California – was of an intern asked to pronounce someone dead. He promptly walked into the hospital room, declaimed “I pronounce you dead,” and left.
So what happened when a group of trainees were instructed in proper death records?
Suddenly all the numbers changed.
Heart disease deaths fell by 54% – far more effective than even the most efficient CCU.
Influenza and pneumonia deaths tripled – rising up to 11%. Cancer increased from 11% to 16%.
The conclusion – after doctor training, the causes of death change after death.
But what’s truly disturbing about all these “causes” and presumed “causes” of demise? They’re not accurate, no matter how well trained doctors are in “charting”.
Because the real cause of death is best understood through autopsies.
And they are now rarely performed.
Why? Cost. Insurers won’t pay. Effort. Trouble with families providing consent.
And great institutional reluctance. Hospitals and doctors often don’t want to know what killed a lot of people.
Because autopsies will show what they missed. And they miss a lot.
More than we can know with present day technology.
The Evidence of History
Overall, perhaps medicos should not feel so bad. Evidence based studies are not performing well in other arenas.
Consider the strange case of Giovanni Patalucci – the Italian Schindler.
Patalucci was police chief in Fiume, a part of the Dalmatian coast which is now Croatian and no longer Italian. He was said to save the lives of 5000 Jews before dying, himself another victim of the Nazis, at Dachau.
Patalucci is a martyr of the Catholic Church. A film was made of his life. Piazzas throughout Italy are named for him and his heroic resistance. His name bears witness at Yad Vashem in Jerusalem as one of the just. Michael Bloomberg honored him in New York.
All of these “facts” are true. Then the NY Times broke the story:
Patalucci was not police chief but an assistant commissioner enforcing race laws.
A higher percentage of Jews from Fiume died than in almost any part of Italy – more than 80%. Many were probably sped on their way to the gas chambers by Patalucci.
He was an active fascist and Nazi collaborator, except the Nazis suspected him of embezzlement and treason before they killed him.
In other words the evidence – and the history, the story, the heroism – were all wrong. Dead wrong.
Fabrications. Aided by a Vatican interested in an Italian hero, a family that wanted a pension, a bishop cousin, and the search to find Italian “heroes” who had not played ball with the Germans.
Evidence is only as good as the methods used to obtain it. Much of present “knowledge” is the result of shoddy record keeping, inadvertent survival of written reports, ideological selection, and outright lies.
So reader, beware. All those “pooled analyses” used to define what treatments work and don’t work may have been infected by a host of factors – including unconscious biases – that always afflict clinical studies.
We can learn from history. We need to. Including that what is written is often wrong.
Even if the records – and the evidence – said it was right.
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