LETTER TO THE EDITOR: Individualism in Clinical Decision-making

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I found a statement by Dr. Peter Bach in the August 15, 2012, issue of The ASCO Post (in the article, “As Conflicting Guidelines Evolve, Experts Continue to Debate the Merits of Cancer Screening”) very troubling. To wit:

There’s a cognitive dissonance between the practice of evidence-based medicine and how we train doctors to make clinical decisions. And they are fundamentally different. I think that this is going to be a generational change. As we shift to doctors who are brought up more on the ability to evaluate and utilize comparative effectiveness research when making clinical decisions, rather than relying on personal experience or intuition, the use of cancer screening tests will become more strategic.

In my opinion, this is an example of utopian statism, as it assumes that all cancer-screening issues will be solved through centralized research and that there will be no outliers who require an individualized approach to their problem. Not only is this statement chilling coming from someone who helps set national policy, it is an insult to all us “old and in the way guys” who work hard to critically evaluate data and do the best thing for our patients on an individual basis.

This statement is anti-doctor (let’s be honest, anti–profit-making doctor), and it is anti-individual, which by definition is against the Hippocratic oath. Furthermore, we have instituted these sorts of solutions over the past 45 years (diagnosis-related groups, current readmission policies, etc), and they have led to a dysfunctional system with high demand, high costs, clinician shortages, and generalized dysfunction, where the individual can get lost if not for doctors with “personal experience” and “intuition.”

I would like Dr. Bach and his colleagues to at least consider that not all patients fit nicely into a bell-shaped curve and that experience and acumen (the so-called art of medicine) is what keeps our current system from being a top-down bureaucracy. While I applaud attempts to standardize decision-making in oncology (I use NCCN guidelines frequently), I do not feel that patients should be put through a cookbook approach to their care.

In my opinion, a true patient’s bill of rights would state that guidelines, best practices, evidence-based medicine, pathways, etc, can only be used by doctors and patients to make complex medical decisions and cannot be used by the government and the insurance industry to ration care. I can assure you that no member of Congress nor Dr. Bach would want to be treated in such a sterile one-size-fits-all manner.

We need new and innovative ideas that empower patients and doctors, and not policymakers in Washington, DC (or even from Memorial Sloan-Kettering). Costs cannot be restrained nor compassion maintained through centralized planning that further insulates individual patients from their care. The 20th century was proof enough of the failure of collectivism. Why are physicians like Dr. Bach attempting to reinvent what has already bankrupted the system both financially and morally while claiming to be saving it? ■

—Jonathan Schwartz, MD
Tucson, Arizona

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