Remember the words evidence-based care. They are likely to be very much a part of your future. To its advocates, evidence-based care follows medical treatment guidelines and protocols developed by experts, based on the scientific literature—as reported in medical journals and scholarly reports. If all doctors follow the same protocols, they argue, patients with similar conditions will be treated the same way. Wide variations in the practice of medicine would be replaced by uniform, standardized treatments.
Don’t you want your doctors to base their advice on scientific evidence? Don’t you want them to follow guidelines that have been written by reputable scholars who have surveyed all the relevant literature? So what’s not to like? A lot, it turns out. Think about the calendar you keep on your laptop or your cell phone. It’s probably an invaluable aide to help you organize your life. Now suppose that instead of being your servant, the calendar becomes your master. What if there were a rule that says you can’t do anything during the week unless it is on the calendar by Sunday. Call this “calendar-based scheduling.” Instead of being an aide, the calendar would quickly become an oppressive barrier to your freedom of action.
The same principle applies in medicine. Protocols and guidelines can be helpful or harmful, depending on how they are used. And there are six reasons why such guidelines—in the wrong hands—can reduce the quality of care you receive.
First, in most areas of medicine, there are no treatment guidelines, and where there are, they are often unreliable, conflicting, and incomplete. Even for something as seemingly straightforward as deciding when women should get mammograms, the advice is conflicting. If insurers have to choose among conflicting and inconsistent guidelines, which ones do you think they will choose? The ones that cost them less money, of course.
Second, even well-established guidelines are inevitably written for the average patient. But suppose you are not average. Are doctors free to step outside the protocols and give you care based on their training, knowledge and experience? Or will they be pressured to stick to the cookbook, regardless of how the patient fares? Health plans always say that doctors are free to step outside the guidelines if they have good reason for doing so. But if they have to fill out multiple forms and jump through many hoops to make this possible, they will be tempted to conform to the guidelines even if that’s not the best choice for you.
Third, guidelines are often written by people who are not disinterested. One study found that 56 percent of the doctors who helped write guidelines for treatment of heart ailments had potential conflicts of interest. These conflicts are more common than is generally realized. Writing in the New York Times, University of Texas law professor Ronen Avraham made the following observation:
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