That said, the comments of “R Chaturvedi” and “LL” are worth reading, as they will likely represent some of the “political” discussions of the future. Chaturvedi expresses skepticism that it is possible for Evidence Based Medicine processes not to be corrupted by economic forces. I am myself satisfied that here a large number of physician leaders and others involved in health care policy know how to prevent economic interests from subverting processes that are set up to determine whether sufficient evidence exists that a medical intervention is efficacious. In fact, the continued existence of skeptics such as Chaturvedi will keep the guardians of the processes on their toes.

“LL”‘s comments, I believe, suggest where the political debates may occur in the future. First of all, what ultimately we are talking about in both the health care reform and EBM discussions is what the government should use tax funds to pay for.

It is an even bigger issue when we bring in the issue of “tax expenditures” (i.e., what is deductible from, say, corporate taxes), since the employer deductions for health care plans are now part of the political debate. The discussion of taxing “high cost plans” could well impact some of the medical interventions that “LL” might wish the sub-specialists to be paid for. Such payments in an EBM world likely would require government-sponsored panels of experts deemed not to have a potential conflict of interest determine if those interventions meet EBM standards.

“LL” likely knows sub-specialists who, like most of their colleagues, approach their profession with the highest of integrity. Chaturvedi probably suspects that there exist relationships between some physicians and pharmaceutical and/or medical equipment manufacturers that would not pass his or her own definition of absence of economic incentives in promoting a medical intervention.

As Dr Berg himself suggested, the American health care system lags far behind the rest of the world in incorporating EBM principles into decisions as to what government will pay for. Maybe the sentiments that “LL” proposes will prevail in the political debate, but we will see.

if you notice, most of researchers in EBM are not the clinicians at the bedside, and not specialists.

if you are going to have EBM, guidelines, they have to be published by specialists who are currently practicing in the special field.

if you have a family medicine guy comes up with “EBM” guideline on the utility of perioperative 2D transthoracic echo, they’d probably say there’s no evidence to support its use due to their bias against specialty care and lack of understanding in the subspecialty. Only cardiologist and anesthesiologist who are dealing with the situation everyday are even qualified to conduct the research.

Marcia Angell, the former editor of the New England Journal wrote, “Physicians can no longer rely on the medical literature for valid and reliable information.” It makes me wonder why we want to base an entire system on it.

Any person that sits on any of these panels is subjected to an extensive review of all that person’s professional and financial activities. In fact, the reason that these studies of the evidence base for a given therapy or intervention are given great weight, is that anyone who has studied what they do and how they do it will be convinced that the processes are fair, and that the participants in the process are uncontaminated by any conflict.

All of the participants are well known to their colleagues, and their professional work is a matter of record. Failure to disclose any kind of conflict whatsoever would not only assure the removal of the miscreant from that panel, they would be unlikely to be invited to participate in any such panel in the future.

Peter Q. Eichacker, M.D., Charles Natanson, M.D., and Robert L. Danner, M.D.Surviving Sepsis — Practice Guidelines, Marketing Campaigns, and Eli Lilly
NEJM Volume 355:1640-1642 October 19, 2006 Number 16