Reform in its purest sense recognizes that health care in this country can be better— not only from the commonly discussed standpoints of access and cost but also those of quality and reliability. The challenges are numerous and daunting and some of the most promising solutions are actually outside the public eye.
The first of these dubbed “evidence-based medicine challenges the very way doctors make decisions. The mention of evidence seems flummoxing in itself: Isn’t medicine already grounded in evidence? In fact, some estimate that only a quarter of medicine is evidence-based.
But that’s not at all an indictment of the medical field. It attests instead to the unfathomable complexity of the human body. The possible diagnoses and treatment options at a physician’s disposal are innumerable, especially with an increasingly older and sicker base of patients who commonly suffer from multiple diseases at once. The intuition of a physician, popularly idealized to fiction, is only so good at sorting through it all.
Variation is the bane of modern medicine. Think about first, second, even third opinions— they can’t all be right. Evidence trumps a doctor’s intuition, but medicine suffers from an evidence deficit. The problem is once a treatment is found at all effective, the influx of further evidence— regarding when to use it and on which patients— generally halts.
The treatment of diabetes offers a fascinating illustration of evidence-based medicine’s promise. Diabetes treatment currently targets the disease at its roots by keeping blood glucose in check. But a physician named Dr. David Eddy found that treating the downstream symptoms (heart attacks and strokes) with a cost-effective concoction of aspirin and generic drugs improved outcomes by 60 to 80 percent and promised $8 billion in savings.
Desperately needed is more funding for clinical trials— the gold standard of medicine— that compare the effectiveness of different treatments. These, in turn, are translated into protocols, guidelines and general knowledge that standardize medicine and make it safer, more reliable and more cost-effective.
Indeed, the unsustainable medical costs in the United States arise largely from self-destructive assumptions of ours— first, that more care means better care; and second, that cutting-edge (and expensive) treatments and technologies are necessarily better. Both are frequently untrue.
And then there is the monumental challenge of health disparities, easily one of the defining social issues of our time. It was Martin Luther King, Jr. who famously declared injustice in health care the most appalling inequality of all. On the whole, racial and ethnic minorities bear the brunt of more prevalent disease, differential health care and poorer outcomes.
Access is part of the problem; uninsurance is unconscionably high in minorities, with access to primary care lacking and emergency room visits inordinately high. But even if we managed to cover 97 percent of the country through reform, we’d still have widespread health disparities.
Our system is one that performs generally well at the top of the spectrum but quite poorly at the bottom. The data are shocking. Blacks, for instance, die from cancer at a 37 percent higher rate than the norm and are nearly three and a half times more likely to have a lower limb amputated due to diabetes. Blacks and Hispanics are, respectively, 27 percent and 40 percent more likely to die from diabetes. Hispanics more commonly suffer from cervical, gallbladder and stomach cancer and are less likely to receive beta-blockers when hospitalized with heart attacks. And there are literally scores of these statistics.
Health disparities result from various social, economic and environmental conditions. Think about people whose houses are inadequate for health; whose lack of education bars them from understanding basic preventive habits; whose jobs pay very little; whose locales are marred by some environmental hazard or whose communities lack sufficient access to doctors. In all these scenarios, people will suffer from poorer health status.
Then there are the eye-opening studies showing that minorities and the poor often do not receive the same level of services offered by health providers to more affluent white patients— namely more high-quality, high-technology care— despite similar coverage and access to care, and even when one controls for factors such as the health provider, health insurance, health problems and job.
Such disparate care, if not discrimination, illustrates the complex cultural and linguistic barriers that can arise between patient and physician. It is more imperative than ever that physicians understand and take into account the many cultural factors that affect their patients’ health. In this regard, medicine is an agent of social change since, after all, good health gives anyone a fighting chance.
Excellence is seldom achieved, much less sustained, without the humility to recognize weaknesses and vow improvement. Drawing awareness to the range of weaknesses in health care is key. Ultimately, much of the progress will come by addressing lesser-known issues like medicine’s evidence deficit and disparities in health care.