Damning Evidence

An old friend was in town this weekend. She's in residency now and mentioned the buzz around this JAMA story about how evidence-based medicine (EBM) was put on trial, and lost.

I was all set to blog about it, but found that new blogger Kevin, M.D., had beaten me to it. Check out his nice summary of the case, in which a resident (and residency program) was successfully sued for adhering to federal guidelines on PSA (prostate-specific antigen) testing.

What gets me is that those USPSTF guidelines are put in place, not just to save money but to save anguish, fear, and unnecessary surgery. There are false positives -- which can lead to biopsies and interventions that carry risks. There are true positives that lead to surgeries or radiation, also with risks. What's more, these interventions have not been shown to prolong or improve life.

But a jury (supposedly, a jury of the physician's peers) found that this pile of evidence and statistics means nothing -- any man over 50 should get the PSA blood test.

And yet, consider what a jury would say if the doctor neglected EBM and ordered PSA tests on people who didn't need to be screened. What if that doctor aggressively followed up a high PSA and started all kinds of interventions that did nothing but disrupt a patient's final years? Is that what they really want? or would they turn around and call it malpractice?

The title of the JAMA piece is "Winners and Losers", and it ends on a truly discouraging note (the winner = the plaintiff's lawyer). The only way I can deal with these miscarriages of justice is to believe that the defendant's lawyer dropped the ball. The author/defendant indicates that they never responded to the plaintiff's attack on EBM -- they seemed to rest on the facts of the case, and the national guidelines.

So, I hope that maybe a better defense lawyer could have responded to the attacks, persuaded the jury, and won the case. This is my wishful thinking, of course, and is increasingly unsupported by the evidence.

UPDATE: the link to the original post at Kevin, MD is fixed. And the original, original article is from the January 7th 2004 JAMA, "Winners and Losers".