Sharon Sakson was walking into her kitchen to make a sandwich one February afternoon when a sudden burst of what felt like indigestion made her change her mind. She went to bed, hoping the pain would pass quickly. Instead, Sakson, then 51, lay there for hours, listening to her six show dogs bark in the background as the crushing sensation in her chest became so intense, she could barely breathe. Finally, the agony subsided, but when it returned the following day, a friend insisted on calling an ambulance. At the hospital, doctors informed the Pennington, New Jersey, resident that she’d had a heart attack, one that had left the lower part of her heart damaged.
Five years later, “I feel like I have a sword over my head,” she says. “Every time I get a pain, I’m afraid it’s another attack and that this time I might not survive.” What hurts even worse: She suspects her heart attack could have been avoided.
When Sakson was just 40, her blood pressure was high enough that her gynecologist suggested she see a specialist. It remained elevated at each subsequent annual visit to the new physician, yet that doctor prescribed only one low-dose medication for years, despite overwhelming evidence of the dangers of uncontrolled hypertension—and National Institutes of Health treatment guidelines, which urge doctors to increase the dosage or add a second drug until the numbers are normal.
We’ve heard a lot about evidence-based medicine lately—the notion that doctors should treat their patients with the drugs, surgeries, and other fixes that have been proved to work for their condition and not use remedies for which proof is lacking (or at least be up-front with patients if they do). This wouldn’t seem to be a radical idea, but it’s not how many doctors practice.
Too often, they’re influenced by the pronouncements of other doctors in their field, self-serving presentations by drug and device companies pushing their products, and the experiences they’ve had with their own patients, says Richard A. Deyo, MD, a professor of evidence-based family medicine at Oregon Health and Science University. “Doctors routinely fool themselves by thinking, ‘In my experience, this treatment works,’ when rigorous studies in hundreds or thousands of patients may show it doesn’t,” he says.
How often does this occur? One New England Journal of Medicine study found that patients get only 55 percent of the care that’s recommended for the leading causes of death and disability. Similar research in children showed they get just 47 percent—and a mere 41 percent of preventive steps that are proved to help. “It’s incredibly frustrating when we know what the best treatments should be yet patients aren’t prescribed them,” Dr. Deyo says.
This isn’t just a matter of missing out on the best care. It’s a waste of precious health-care dollars. “If we don’t focus on the evidence, we may spend a lot of money for things that are of marginal benefit or no benefit at all, without even knowing it,” says Gordon Guyatt, MD, a professor of medicine at Canada’s McMaster University, who coined the term evidence-based medicine.
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The bottom line on guidelines
When your doctor suggests a treatment, you should hear the word evidence in his or her explanation. But that doesn’t mean physicians should slavishly follow every treatment guideline you might dig up online. These are good reasons your doc might take a different tack:
You’re not average, so your treatment can’t be either. “Good doctors view guidelines like suits off the rack. You’ve got to tailor them so they fit,” says Otis W. Brawley, MD, chief medical officer of the American Cancer Society. If guidelines recommend a cancer drug that can be toxic to the heart and you’ve got a history of ticker troubles, for example, your doc might prescribe a different drug. Plus, guidelines aren’t generally written for patients with multiple ailments. If you have several chronic conditions, combined guidelines might leave you taking dozens of drugs daily, with potentially dangerous interactions.
Not all guidelines are based on solid research. “Some guidelines seem to be thinly disguised efforts to push the agenda of the professional groups that created them,” says pain expert Dr. Chou, who helped develop guidelines for back treatment. The best guidelines are created by a consortium of organizations, clearly state how evidence was evaluated, and give a letter grade to each recommendation, showing the amount of science that exists to support it.
There isn’t enough evidence to know the best approach. For some conditions, the research is too weak to give much help. For others, the evidence is strong for an initial treatment, but if that fails, there’s no clear way forward. Still, says evidence-based medicine expert Dr. Guyatt, your doc should always make it clear when the benefits and risks of a treatment are uncertain so the two of you can take that into account.
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