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Evidence-Based Medicine in Health Care

. . . or "Marketing Dollars are at Work Here"

April 1, 2015       Leave a Comment
By: Dr. Lee Newton, Eye Care

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Evidence-based medicine derives recommendations and treatment from fact and results from unbiased clinical studies and observations.
 

Any health care provider has, or should have, a working knowledge of what constitutes evidence-based medicine. During our education and training, we were taught to pay close attention to claims made by a drug or device manufacturer. In particular, to be aware whether the author of a clinical study may have bias or conflicts of interest, disclosed or otherwise (Does this individual or firm stand to benefit from widespread use of a particular drug, instrument, or procedure?).

Pharmaceutical companies have figured this out. They know that patients are more likely to ask their doctors whether a drug or treatment may help them or simply for an Rx for the medication when they see the doctor - if the patient recalls the advertising message.

Evidence-based medicine derives recommendations and treatment from fact and results from unbiased clinical studies and observations. Certainly, the ads show - or at least imply - that the drug in question increases your chances of driving a fancy car....associating with attractive people....earning a high income....losing weight....right?

Many physicians have a love-hate attitude toward this type of marketing....on one hand, they're pleased that their patients are more aware of their health care - and show up in their office so a more complete physical evaluation may be performed...on the other hand, this market to the user, not the prescriber" approach may lead to inappropriate care through self-diagnosis and treatment. Media messages aren't the only offender....we're guilty of straying from evidence-based medicine in other ways.

For example, in my profession, I have heard a lot of hype over "high definition" as it relates to one's vision and the fabrication of lenses?."Buy these lenses and you'll see the world in a way you never have". What the message DOES NOT say, however, is that the basic neurochemical and electrical mechanisms that define the visual process are not high-definition...the eyes focus a somewhat blurry image (even if you don't need corrective lenses) and the neural mechanisms of the brain improve the perceived quality of that image until it meets our previously-determined concept of "clear". I don't care how much money you throw at a pair of lenses - great lenses can't enhance the wiring in our brains or the resolution of our retinas.

How does evidence-based medicine apply here? There are clinical studies (such as the one found here: http://journals.lww.com/optvissci/Fulltext/2011/02000/Clinical_Assessment_of_a_Customized_Free_Form.9.aspx) in which patients with various levels of correction wore both "normal" and "high-definition" lenses. The results indicate that the high-definition lenses made a small subjective improvement in perceived visual quality....for patient primarily with higher prescriptions....but the level of improvement was unable to be quantified by objective means. This implies that yes, in some cases, highly specialized lenses indeed help patient see better.....so this is one way that evidence-based medicine may assist in making an appropriate recommendation as opposed to a blanket recommendation (sell, sell, sell!).

Here's another example specific to my profession: A relatively new (in the last decade) eye scanning/imaging device has been used as an "alternative" to a dilated retinal assessment that occurs within a complete eye examination. That sounds good, doesn't it? A non-invasive retinal "scan" and no inconvenience of recovering from dilating drops? Back to work immediately after your appointment with no lapse in productivity? Driving from your appointment on a bright sunny day with no discomfort?

Here's the problem: Dilation of the pupils and a thorough examination of the internal structures is still the medico-legal standard of care for what constitutes a complete eye examination...and while it doesn't need to be done in every case (you don't need to have your eyes dilated to determine why your contact lens is bothering you), it needs to be done regularly. And there is no substitute for having your eyes dilated, if you want to make sure they are completely healthy.

Therein lies the problem: Should a doctor imply that a patient spend $39 (average cost) for a retinal scan so they can "avoid" dilation, or should they simply recommend and perform dilation of the eyes at appropriate intervals?

How about both? Can we dilate your eyes one year and scan them the next? That would indeed seem to be the ideal situation or alternative. But that wouldn't pay for the instrument... and will a nearly 6-figure instrument pay for itself if little to no additional revenue is generated?

Is the recommendation one that's in the patient's best interest or another profit center for the office? Would the conversation be, "your insurance provides your basic examination at no cost to you. However, if you want a really good job with no drops, you have to pay $39." ??

Those are the real questions.

Evidence-based medicine needs to be at the forefront of any health-care based recommendation - along with a complete list of alternatives, and the potential risks and benefits of each. Otherwise we risk taking care of ourselves and our pockets rather than the individuals who place their trust in us. Even on the INTERNET and social media, messages contrary to evidence-based medicine are rearing their ugly heads. You may have heard of "astroturfing" ... .if you had asked me a year or two ago, I would have said that's a term for someone installing astroturf at a stadium - but thanks to the Palm Beach Research Group, I now know better.

As many of you likely know, astroturfing refers to (courtesy of Wikipedia.org) "the practice of masking the sponsors of a message or organization (e.g. political, advertising, religious, or public relations) to make it appear as though it originates from and is supported through grassroots participants.

It is a practice intended to give the statements or organizations more credibility by withholding information about the source's financial connection...The implication behind the term is that there are no "true" or "natural" grassroots, but rather "fake" or "artificial" support, though some astroturfing operatives defend the practice... Sometimes one individual operates over many personas to give the impression of widespread support for their client's agenda. Some studies suggest astroturfing can alter public viewpoints and create enough doubt to inhibit action."

Palm Beach Research Group, in their daily news service to which I subscribe, highlighted astroturfing via a TED talk by journalist Sharyl Attkisson. Watch it here: http://www.realclearpolitics.com/video/2015/03/14/sharyl_attkisson_gives_ted_talk_on_astroturf_and_manipulation_of_media_messages.html Attkisson refers to astroturfing as "artificial paid-for reality" which in essence consists of special interests attempting to sway opinion and create their own grass-roots movement on behalf of their interests. She implores us to be on the lookout for astroturfing in our daily lives, the clues being as follows:

1. Use of inflammatory language in an attempt to debunk a myth that isn't really a myth, where the insistence of a myth is itself a myth.

2. Attacks on individuals or organizations surrounding issues - rather than a discussion of the issues.

3. Instead of questioning authority, they (astroturfers) tend to question those who question authority.

Attkisson describes instances of large health care companies, such as drug manufactures, signing up for false or disguised social media profiles in an attempt to sway public opinion. She even described one account where a well-known author was not able to clarify an inaccuracy in a review of his own work on Wikipedia, because Wikipedia did not view him as an authority on his own work. However, she says, sponsors of Wikipedia (read $) are able to clarify the facts as they see fit. Sardonically, the best definition of astroturfing I could find came from Wikipedia.

From failure to abide by the principles of evidence-based medicine to astroturfing, reality-manufacturing is rampant in society. I hope you now feel better about your ability to detect it.

Until next time, remember... even astroturf is greener over the septic field! As always, I invite your questions or comments.

Please direct them to: leenewton@newtoneyecarecenter.com.

Dr. Lee Newton

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Dr. Lee Newton, Eye Care

Dr. Lee Newton has provided eye care services in Bay City ever since graduation from professional school. He and his family consider the Bay City area a great place to live, work, learn, and play!

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