The power of knowledge in the practice medicine used to be given only to us physician wizards of the medical Land of Oz. You novices had to stay on your ignorant side of the green curtain with Dorothy and her witless sidekicks. Those days are gone; any Dorothy, Toto, or Scarecrow with access to the Internet can get access to good information about what’s best care in medical practice.
In fact, a smart traveler on this new Yellow Brick Road of better, evidence-driven health care can not only help themselves get better care, but save lots of money in their out-of-pocket medical expenses and reduce chances of a complication from an unnecessary test. As important, the powers that be in health care — politicians, insurance companies, employers, physicians and hospitals, etc. — can all help us and each other use it to reduce health care costs and improve care.
A great example of this is the Choosing Wisely Campaign, about which I have written previously. In it, a number of physician experts have banded together to identify wasteful tests in their areas of specialty. Want to know what relevant experts think about when you do and don’t need allergy tests, bone density tests, EKGs and stress tests for heart disease, chest x-rays before surgery, or what five tests and treatments in cancer care that cancer specialists think you should question? Go to the website at choosingwisely.org/?page_id=13.
Want to know how frequently you need a pap smear, or that most women don’t need them every year, or that women under the age of 21 don’t need to start having them as soon as they start having sex? Visit cancer.gov/cancertopics/factsheet/detection/Pap-HPV-testing. Want to know the most up-to-date, scientifically supported medical thinking on an array of topics from cranberry juice for urinary infections to whether taking zinc actually helps prevent the common cold? Visit the Cochrane Collaborative at cochrane.org.
One powerful application of this kind of knowledge is in an emerging concept called shared decision making. SDM is the old risk-benefit discussion with your physician on steroids. In the SDM process, a patient and-or family works through a data-driven, patient-centered decision making process about a proposed treatment. The process is supported by good, evidence-based statistical information about the risks and benefits of the treatment. Content language is patient-friendly, and the process usually takes place outside the pressures of the physician office visit. Dartmouth Hitchcock Medical Center in New Hampshire has a small library of SDM decision support tools available to patients online at patients.dartmouth-hitchcock.org/shared_decision_making/decision_aid_library.html.
What this all means is that patients can now often find out for themselves “What is the evidence for that test or treatment?” When they get a recommendation for a test or treatment, they can ask their health care provider whether they really need it. And then, before making a decision, and therefore often before paying out of pocket for it, the patient or family can start comparing what they are told with the growing body of evidence-based testing and treatment recommendations that are available to anyone with internet or library access.
The real potential of evidence-based information from credible sources to change health care, however, can only be realized when those same powers that be noted above start supporting patients in its use, start consistently using it themselves, and start pushing each other to do both of those things.
For example, employers should be pushing insurers to design insurance benefits that support patient use of evidence-based information. A state Legislature considering changes in health care laws should be asking anyone who stands before them and asks that their sacred health care ox not be gored in some budget or policy battle “What are you / your profession / industry doing to support evidence-based practice?” That Legislature should be systematically asking how state laws support or undercut use of evidence-based care.
In other words, every constituency in health care must help support evidence-based care by every other constituency, and by its own practices. It all takes heart, brains, and courage, and it’s the only way Dorothy and Toto are getting back to the Kansas of safe, affordable, effective health care for all.
Erik Steele, a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems.