Trendspotter: Patient Opposition to Evidence-Based Medicine

Patients believe that more care is better, that the latest and most expensive treatments are the best, that none of their doctors provide substandard care, and that evidence-based guidelines are a pretext for denying them the care they need and deserve.

These are the main conclusions of a new Health Affairs study that included focus groups, cognitive interviews, and an online survey of consumers aged 18 to 64, most of whom were employed and insured.

Physicians on the front lines of patient care will be not be surprised by these findings. Most of you know plenty of patients - especially people with good insurance - are always demanding the latest and greatest tests and drugs, whether those will help them or not. Plus, it’s the American way: After being subjected to TV commercials since childhood, we tend to believe that “new and improved” products must be better. Moreover, the steady drumbeat of media reports about the latest medical “advances” dramatizes the value of the new.

Nevertheless, for anyone who supports healthcare reform and believes that there is a way to save our system from collapsing of its own weight, the results presented in this paper are disconcerting. A large body of research has established that a lot of U.S. healthcare is substandard and that many patients do not receive all recommended care. Yet focus-group participants brushed off this information, saying there must be a good reason for doctors not to provide that care.

Similarly, consumers displayed a lack of understanding of what “medical evidence” is. Many thought it was related to their own medical records or test results. They viewed clinical guidelines as inflexible and as a tool of payers to prevent their physicians from choosing more expensive tests and treatments. Some patients may have picked up these attitudes from doctors who dislike what they regard as cookie-cutter guidelines.

But group-practice physicians who follow these protocols - most of which come from specialty societies - seem to accept them, as long as they can override them in individual cases.

Respondents believed that all medical care meets minimum standards of quality, and only half had heard about studies to find out which treatments work best. A full third of the consumers agreed with the statement that “medical treatments that work the best usually cost more than treatments that don’t work as well.” Twenty-seven percent disagreed with the statement, and 40 percent weren’t sure how they felt. When you combine these results with consumer disapproval of guidelines, the comparative effectiveness research authorized by the health reform law could easily provoke a public backlash.

Since consumers believe that more care is better and that guidelines represent a minimum standard of care, the researchers point out, they’re unlikely to use performance data to choose among physicians and hospitals. That’s also not surprising, considering the fairly low level of consumer interest in public report cards. But it doesn’t bode well for efforts to use consumer preferences to put pressure on providers to deliver higher-quality care.

Consumers were also questioned about their behavior during visits to their physician. Contrary to many doctors’ impressions, 60 percent never brought any printouts from Web sites with them, and 20 percent said they’d done so only once. Fifty-five percent said they never took notes during visits, and 28 percent said they never brought a list of questions. Most tellingly, 59 percent said they had held back from asking questions during a visit, either because they didn’t know how to ask them or because the doctor seemed rushed. The prevailing sentiment was that physicians were the experts, so patients trusted them to make the right decisions.

There are plusses and minuses for physicians in this study’s results. On one hand, patients seem to trust you to do the right thing and have little faith in report cards. On the other hand, they don’t perceive a difference in quality among physicians, and they’re suspicious of any recommendation that they take a conservative, low-cost approach to their own care - even if it’s the right thing to do. If you can’t use nationally approved, evidence-based guidelines to justify your advice or your orders, that opens up a big communication gap with your patients.

What all of this indicates is that a great deal of education will be required to get patients to accept the fact that they shouldn’t have everything medicine has to offer. And it’s unlikely they’ll ever accept the cost argument. So physicians will have to figure out how to explain, in the short space of a visit, why more isn’t always better.