Commentary: Improving The Medical Decision-Making Process
نویسنده
چکیده
I want to argue the case for the evaluative clinical sciences and the need to support a national program to assess the outcomes of medical care. For too long, and at peril to the welfare of patients and the public as well, we have neglected that essential part of medical science whose job it is to establish the validity of clinical theory and help physicians and patients reach the right decision in their choice of medical care. The result is an intellectual crisis in the scientific basis of clinical practice, which is of growing significance for medicine. The outcomes of many treatments, including major surgery, invasive and risky diagnostic procedures, and such costly clinical choices as treating a host of acute and chronic medical conditions in the hospital, are not well understood simply because the necessary evaluations have not been done adequately. In many clinical situations, the physician’s treatment and outcome preferences unduly influence the clinical decision process, in part because of confusion about the probabilities for outcomes but also because so little attention is now given to the crucial task of helping patients discover and choose the care they really want. The scientific basis for quality assurance in medicine remains retarded in its infancy, unable to cope with the growing demand for sophisticated technologies to evaluate differences in outcomes among health care providers. Consider the following statistics. A resident of New Haven, Connecticut is about twice as likely to undergo a coronary bypass operation as is a resident of Boston; for carotid endarterectomy, the risks are the other way around. The numbers of knee and hip replacements per capita are much more common among Bostonians, while New Havenites experience substantially higher risks for hysterectomy and back surgery. The risk of hospitalization for Boston is substantially higher for a host of acute and chronic medical conditions, including back pain, gastroenter-
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