Why not Evidence-Based Medicine?

Former President John F. Kennedy said: “Mothers all want their sons to grow up to be president, but they don’t want them to become politicians in the process.” I would add mothers also want their sons to be doctors.

In terms of medical care, when your doctor stands in opposition to your political representative, which one will you back? The answer may just be in the book Unhealthy Politics by Eric M. Patashnik, Julis-Rabinowitz Professor of Public Policy, Professor of Political Science, and Director of the Master of Public Affairs program at Brown University. Patashnik is also the editor of the Journal of Health Politics, Policy and Law as well as Nonresident Senior Fellow at the Brookings Institution and a Fellow of the National Academy of Public Administration.

Dr. Eric M. Patashnik spoke with us on October 15, 2018 as part of the Price Governance Salon series. He offered vital insight into healthy policy and evidence-based medicine.

The U.S. medical system is considered to be the most advanced in the world; we know it is one of the most expensive ones for sure! However, Patashnik indicated that many common treatments are not based on sound science. In fact, many procedures might not even be necessary.

Patashnik started the talk with the Knee Surgery Case, study that set out to determine what treatment is the really best for patients with knee injuries. He detailed the study’s findings of no FDA guidelines for surgery and that key information patients and doctors need to know is often lacking. “Drug A may be better than Surgery B.” For Patashnik, the issue is not about provability or cost control, rather it is the quality and safety of the medical treatment patients receive. Everyone is harmed when the medical care system is inefficient or not based on evidence; all Americans should care about the mismatch.

“Failure to generate, disseminate, and use medical evidence harms all Americans, including the affluent and well-insured. It is systemic. And it is not a partisan issue, they (different parties) all thought it was a problem.”

Three Puzzle Pieces

Although all politicians acknowledge it is a problem, Patashnik and coauthors found there are three puzzle pieces holding back evidence-based medicine from gaining more traction in the medical field or politics:

1.The Public. Patashnik and coauthors used survey experiments to determine national public opinion, which mirrors U.S. population looks to doctors on the health reform, and doctors are the only actors the public trust.

2.Physicians and the Medical Profession. What matters for persuasive communication: first, belief that sender of information is an expert; second, the sender of information shares the recipient’s interests. Yet the medical professions are also “political entities”.

3.Politicians. Government’s poor performance as a problem-solving institution.

Two stages of government failure:

  1. Agenda Setting: political system is often claimed to have equilibrating, “self-correcting” properties. (“Zero Credit Politics”: survey shows there’s little public demand for national problem solvers on health reform.) Politicians have no independent ability to make a good move on a medical evidence controversy. For the public, any politicians stand on the opposite from doctors are not trustworthy or not a good person.
  2. Decision Making: Polarization, parity of party competition is the incentive to try to undermine the health reform. When two parties are polarized and highly competitive, the majority party feels compelled to “go it alone” on major legislation, the minority party will oppose. Strong incentive to discredit the empirical claims and analyses offered by the other party. Incentive for disagreement are so sharp.

To promote evidence-based medical system, Patashnik suggested we should build sustainable health reform in a series of actions. First of all, “conceptually distinguish EBM from cost-cutting by publicizing research on treatments that some experts believe are underused”. We should also “use fading of ACA debate as opportunity to gain bipartisan buy-in”. Moreover, it is time to “build agency reputation for competence and relevance. EBM agencies should aim to put ‘pinot on the board’ by focusing on important treatments and controversies.” Last but not least, we should “engage in organizational network building and federated design, strengthen ties to medical schools and communities around the country.”

The problem is that the process is very slow, because evidence or study needs a long time to gain foothold and practice in reality. With more united and efficient governance, we may be able to expect a sustainable health reform. The more “healthy politics,” the better the medical system we could have.