Getting Doctors to Listen: Ethics and Outcomes Data in Context

By Philip J. Boyle | Go to book overview

JAMES LINDEMANN NELSON


Clinical Judgment versus
Outcomes Research?

A Tale of Two Health Care Centers

At a major integrated health care system in the eastern Midwest, many practitioners don't use tissue plasminogen activator (t-PA) despite the evidence of superior outcomes as attested to by the GUSTO II trials. In part this is due to logistics—many heart patients present at satellite clinics not equipped to use this clot buster. Yet most other practitioners in the system, not so restricted, also favor streptokinase. When pressed as to the reasons for their decision, they often say that the GUSTO data are not "clinically meaningful," at least for their populations. 1

At a distinguished community hospital in New York State, the practice pattern is different. There t-PA is used virtually all the time. But the hospital's cardiologists say that they regard streptokinase as a perfectly legitimate therapeutic option. Despite the evidence derived from outcomes research, they were unanimous in saying that they would resist any attempts to influence a physician to use t-PA against his or her better judgment. 2

The moral I want to abstract from these stories is that at least some clinicians regard thoughtful decisions made by working physicians—what I will henceforth call "clinical judgment"—as an appropriate counterweight to the apparent direction of outcomes research. In the first case, this may not seem surprising: the physicians in question do not use t-PA, and hence they are under considerable pressure to argue that electing other anticoagulants is perfectly reasonable. But the second case is perhaps more striking. These physicians all defended using other anticoagulants counterfactually, so to speak, and this despite the fact that the community standard of practice runs smack in the face of using anything other than t-PA. Furthermore, the cardiologists all regarded the research standards involved in the GUSTO II studies to be impeccable and definitive; given the scope and outcome of that trial, the cardiologists thought it extremely unlikely that any further, more authoritative

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