Friday, October 24, 2008


Billy Beane and a couple of Congressmen want to do for medicine what Beane did for the Oakland A's: get rid of all of the talent and then scrape together months of demoralizing, mediocre performance!

Wait, that's not it. He wants information to drive medical decisions, not ignorance, gut feeling, and tradition:

Remarkably, a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures. Studies have shown that most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition . . .

Data-driven baseball has produced surprising results. Michael Lewis writes in “Moneyball” that the Oakland A’s have won games and division titles at one-sixth the cost of the most profligate teams. This season, the New York Yankees, Detroit Tigers and New York Mets — the three teams with the highest payrolls, a combined $486 million — are watching the playoffs on television, while the Tampa Bay Rays, a franchise that uses a data-driven approach and has the second-lowest payroll in baseball at $44 million, are in the World Series (a sad reality for one of us) . . .

. . . Similarly, a health care system that is driven by robust comparative clinical evidence will save lives and money. One success story is Cochrane Collaboration, a nonprofit group that evaluates medical research. Cochrane performs systematic, evidence-based reviews of medical literature. In 1992, a Cochrane review found that many women at risk of premature delivery were not getting corticosteroids, which improve the lung function of premature babies.
OK, now that I've gotten the low hanging joke fruit out of my system, I'm going to admit to my general ignorance of the health care system and register my shock and horror that the medical decisions that affect my life and health were reached by roughly the same deliberative process that landed Pat Mears a four year contract extension immediately following a season in which he put up an OPS+ of 87.

One thing Beane doesn't mention here, however, is that it seems there is a major amount of cognitive dissonance going on when it comes to medical information. On the one hand, everyone agrees with Beane that the documentation and dissemination of medical information is critical. On the other hand, we have an increasingly irrational desire in this country to protect every bit of information that can be even remotely deemed personal, be it medical data, social security numbers, or our mothers' maiden names. Don't get me wrong: privacy is important -- I don't want everyone to know about that course of antibiotics I had to take in college -- but at some point we have to be less paranoid about this sort of stuff.

(thanks to reader Jeffrey Bijas for the heads up on the link)


rob said...

Interesting article on a subject about which I'd like to know more, but let me say that it's no surprise at all that Starbucks pays more for health care than for coffee. I suspect they pay more in salaries to their employees too, and it's not at all clear why that should mean anything.

David said...

I'm a 3rd year medical student so it won't be long before I'm a practicing physician but I'll say that we are preached to all the time about using evidenced based medicine based on the literature. A couple of thoughts on the subject though that we as young physicians and soon to be physicians see.

1. Patients really don't care. I hate to say it, but your average patient simply doesn't want to get better. They are non-compliant with medication, they smoke despite knowing it's killing them, they drink despite having cirrohtic livers, they don't follow up with physicians, they don't eat correctly despite knowing they have chronic kideny disease, they don't lose weight despite the doctors telling them that obesity is their biggest problem.

That is frustrating as a physician. When you see a patient who legitimately wants to get better then you are motivated to work harder as a doctor to help that patient, but when you see crack addict with CKD spend money on crack instead of her medications then abuse the ER 4 times a month to get admitted because she was taking the crack instead of the medicine and charging the bill completely to Uncle Sam because she's on medicaid then it gets disheartening.

No amount of evidence based medicine is going to change those facts. Another thing when we round that I hear all the time from physicians is not wanting to be taken to court by lawyers. I was with an OB/GYN recently who was seeing a pregnant women for the first time from a referal by a family physician who didn't deal in high-risk pregnancies. The doctor was explaining what could go wrong when the woman told the doctor, "Well, I guess I can always sue you if something bad happens." The doctor then refused to treat her as a patient. Maybe that's an extreme example and it's hard not to feel for the pregnant woman because she didn't ask for her child to be high risk, but the doctor seriously doesn't need the headache of walking on eggshells during her remaning 2-3 months of pregnancy because he feels one wrong move will result in a lawsuit. And this is an instance we hear all the time whether it be on the wards during Internal Medicine or with OB/GYN doctors or even Radiologists who are reading graphs looking for breast cancer in exceptionally dense breast tissue.

Those are just some issues regarding a lot of what I hear/see on the wards as student.

Craig Calcaterra said...

David -- thanks for the insight. The best thing about this blog is that I get to hear from people who actually know stuff about the world that most of us don't, so I really appreciate your comments.

As for your comment re: the lawyers: I will always remember when my wife was pregnant with our daughter five years ago. I went to all of the office appointments with her. In one of the early visits, the OB asked me -- casually I thought -- what I did for a living. I told him I was a lawyer. He asked me what kind, and I said so. It was all very conversational and casual.

Flash forward 19 months, and my wife is pregnant with child #2. At one of the office visits, my wife's file is sitting on the table while we wait for the doctor. I know I shouldn't, but I sneak a peak. Right on the front page containing basic info is written the words "husband; lawyer; defense; business lit; no med-mal."

I can't say I blame him for being nervous.

rob said...

Nineteen months? Are you insane?

Craig Calcaterra said...

Apparently. I keep telling myself that it will even out when they're older, but then I remember that I'll be paying for two college educations at the same time.

rob said...

Yeah, I can see that. It's much easier to deal with two teenagers simultaneously than one at a time.

Man, I wash I were your insurance agent.

rob said...

Wish. I wish not wash. (dammit)