I approve of evidence based medicine, but with one caveat. Evidence based medicine seems to forget that half of the job in primary care is listening.
I do think we should do research and clinical trials and studies where the people gathering the information are not biased by knowing who is getting which treatment. We should do studies that are statistically large enough to have mathematical meaning.
However, NNT bothers me.
NNT is the Number Needed to Treat. For example, a treatment for bacterial ear infections for children goes through a clinical trial. In a large, randomized, double blind clinical trial, the new treatment does better than the previous treatment. A little better. The Number Needed to Treat is 5 instead of 6 and this is statistically significant.
And what does that mean? That means that if 5 patients are treated with the new treatment course, one will get better more quickly or respond better.
My thought is always "What about the other four?" They are taking a medicine that is not better than the other medicine, may be more expensive, may not help. Why do we have to treat 5 people to make a difference to one?
Medicine is not exact. Diagnosis, treatment, course expected, side effects, response failure.
The hospital clinic where I worked for 9 years bought an electronic medical record in 2005, an EMR. It was purported to make us faster, more efficient, paperless, cutting edge and we could use templates! And build our own!
I hated it.
I particularly hated the templates. The template was a list of questions for a particular problem, such as ear pain. The computer listed the questions, I could ask the patient the question, check the little box and the computer would generate a narrative from the check.
The computer sentences were so dry, awful and boring that they were nearly unreadable. Each was the same. "The patient says the quality of the ear pain was sharp. The patient says the duration of the pain was 3 days. The patient says..."
One woman came in with ear pain. She said that the pain felt "like someone is kicking me over and over in the ear with the pointed toe of a cowboy boot." That definitely got my attention. It was not on the list of computer choices. I stopped typing and looked at her ear immediately and called the Ear Nose and Throat specialist, who saw her that day.
Then I emailed our head computer geek doctor and suggested that they add that to the list of choices under "quality of pain" in the ear pain template. "feels like someone is kicking me over and over...." He said no.
The computer doctors and hospital told me that I could write my own templates. I said, "I have a template: Why are you here? After that, every patient is different."
I said that if they wanted the computer to ask the questions, why was I in the room? Let the computer see the patient. There is a program where people can log on, fill out a template, email it to the doctor who then either treats, never seeing the person, or says, "No. Come in." The person is charged if he treats them without seeing them, but no charge for reviewing the template if they are seen.
I do use the templates to make sure that I fill out the six things that the biller/coders are looking for. Once I was told that my note was down-coded for an 89 year old on a consult I'd done in the hospital. "You did not identify the quality or intensity of the pain."
"Um," I said, "Her hip was broken and she couldn't walk. Are you telling me that I have to say hurts like shit and she can't walk and 10/10 pain if she tries?"
"Yes," said the coder primly.
Well, it's stupid, but if I have to do it to take care of my medicare patients, whatever.
The forgotten piece in evidence based medicine and our current climate is listening. In medical school and residency we were told that half of primary care, family practice and internal medicine, is psychiatry. How can that be? My schedule says back pain, hypertension, hospital followup, needs antidepressant, sinus infection, as the complaints that people are coming in for. I rarely see colds.
But the schedule doesn't tell the whole story. I see someone for their fourth cold of the year. They didn't come in for the other three. Why this one? They aren't even surprised when I say that it is a virus and they don't need an antibiotic.
Then they tell me that their daughter is back on methamphetamines and they are taking care of the grandchild.
And that is the real reason they are there. To tell me. To tell someone in a safe confidential place.
If I stuck to the upper respiratory template, I wouldn't hear that. If I stuck to the template, they wouldn't feel heard. If I stuck to the template, they wouldn't get what they really need.
With the economic downturn, there were more visits for anxiety or depression or "wonders if needs depression medicine."
We talk and then sometimes a person starts crying and says that they're losing their house, or they've lost their job, or they have to move.
I don't have a pill for that.
More often than not, they decide not to go on a medicine.
They needed my shoulder and a place to weep.
I hope that Congress remembers that sometimes the most important job of a doctor is to listen. We need time to listen. There is nothing that can replace it.