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Luna: Content Out of Context

By Carlos Luna

Thursday, December 7, 2017 | 362 | 0 | min read

The adoption of evidence-based medicine by state jurisdictions tends to polarize workers’ compensation stakeholders, sometimes for good reason.

Carlos Luna

Carlos Luna

Many justify that it is the political machine driving the opposite perspectives. This may very well be part of it, but lack of understanding combined with the improper use of the scientifically based standards by certain system verticals is almost certainly a recipe for varying points of view and disagreement.

Evidence-based medicine not always unequivocal

Proponents for the adoption of EBM in workers’ compensation generally agree that the content is a path leading to improved medical care for injured or ill workers. Various metaphors (e.g., speed bump, guardrails, etc.) have been appropriately used to describe the content’s ability to steady the tempo of decision-making around care considerations ensuring that safety and efficacy remain priorities in the care and claim continuum.

These metaphors, however, miss an important attribute that is evident in a well-developed medically responsible EBM standard: It may not always be unequivocal.

Today, non-clinical professionals often view EBM as absolute standards for the appropriateness of care rather than scientifically based guidance to inform medical decision-making. The use of the content in workers' compensation as a rigid basis for approving or denying reimbursement for treatment is, in large part, responsible for maintaining this perception.

While this application of EBM, when informed by clinical consensus, may be an acceptable use of the content, it is not its sole purpose and the original intent for the guidance.

Certain recommendations for, or against, specific protocols can be very straightforward and have clear guidance that is actionable for clinical professionals, and non-clinical personnel alike. However, ensuring appropriate clinical interpretation of the recommendations by considering each individual patient’s unique medical needs prevents the use of the content from being out of context and avoids perpetuating a cookie-cutter approach in medicine.

The original intended application of EBM was to strengthen weak standards in clinical practice and to increase confidence in clinical decision-making. If the application of the content was more prominent in clinical settings used by medical professionals in workers’ compensation, would the industry view EBM as unequivocal standards, versus trustworthy guidance useful to aid in the care of the individual patient as it was initially intended to be?  

The oversimplification of complex concepts

Publishers of EBM continuously walk a fine line between creating tools and widgets that deliver the content in concise, actionable formats and potentially oversimplifying complex medical concepts that become diluted and dangerous when made to fit into an overly simplistic delivery. This, along with prospectively rigid applications previously mentioned, leads to distrust of the content and breeds opposition among the stakeholders for whom EBM is intended to support.

Opposition among providers outside of the Occupational Medicine specialty for EBM always surprises me. I have had the privilege of interviewing numerous providers who oppose the use of EBM over the last 10 years. Their perspective has a common thread that echoes the issues identified above. And while medical providers are often accused of rejecting the use of EBM standards due to avoidance of oversight and accountability, a more sensible source of their opposition may be due to the oversimplification of the complex medical concepts delivered via poorly engineered EBM tools and inadequately credentialed users of content.

A recently posted blog by a long-term, well respected proponent of EBM documents a young Air Force physician’s disillusionment of medicine due to EBM, among other things. The young physician states that EBM sucks the intellectual challenge and creativity, or as he puts it, “the fun,” out of the art of medicine. He further shares that following the guidelines is the “easy path” and that there is neither “encouragement nor reward for taking the extra mental step” to determine if the guidance fits the patient’s needs, or if a variance is medically appropriate.

I have several thoughts about why the young physician’s disillusionment of medicine may be misplaced. However, the acknowledgement of the lack of reward for varying from EBM guidance, when warranted, in pursuit of the best medical care and health outcome for his patient is telling of a system’s oversimplification of the complex medical scenarios he must work to resolve.

A rigid, oversimplistic application of guidelines will only shorten the cycle for reimbursement but can risk stifling a good doctor’s willingness to invest the time to identify the best treatment plan that will produce the best health outcomes for the patient. This rigid approach to medicine will breed and reward poor practice habits in the clinic, and potentially result in higher medical cost long-term.

Conversely, a doctor unwilling to investigate the best course to recovery for the patient, irrespective of the hurdles encountered, may be subject to criticism for prioritizing other interests ahead of their patient’s needs.

The data is clear. The impact that EBM has on improved health outcomes in workers’ compensation is overwhelmingly positive. Adverse patient and provider experiences are more accurately contributed to the inappropriate rigid use of the content in a system that is engineered to focus on reimbursement versus quality medical care and improved health outcomes.

The pursuit to simplify and streamline solutions has become part of our cultural fabric. Just as technology has made it possible for our society to make advancements in medicine, it will eventually become a vehicle to better deliver these advancements. For now, however, we rely on the appropriate application of EBM standards by qualified professionals in the clinic and beyond, allowing for flexibility when warranted.

Carlos Luna is director of government affairs for ReedGroup, which publishes the American College of Occupational and Environmental Medicine treatment guidelines and drug formulary.    

Comments

Dr. Robert Weinmann Dec 7, 2017 12:01 PM

Luna's comment that "a doctor unwilling to investigate the best course to recovery for the patient, irrespective of the hurdles encountered, may be subject to criticism for prioritizing other interests ahead of their patient's needs" is self-serving and hypocritical. The insurance industry and their yes-quacking Utilization Reviewers consistently put profits before patients -- UR often rejects alternative methods for pain reduction and then squawks when doctors opt for pharmaceutical treatment. That's why arbitrary limits to physical therapy are applied without reliable EBM. The answer is to get the burgeoning number of administrators out of the system. -- robert L. weinmann, MD, Editor, www.politicsofhealthcare.com

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