Correspondence
Outcomes Research
N Engl J Med 1994; 330:434-435February 10, 1994
- Article
To the Editor:
The article by Tanenbaum (Oct. 21 issue)1 criticizing outcomes research troubled me deeply. Her thesis is that outcomes research attempts to replace subjective professional judgment with micromanagement by insurance companies and government. On the contrary, outcomes research can inform decision makers -- including public and private payers, but especially physicians and patients -- and help them make better decisions. Nobody disputes the fact that most therapeutic interventions have never been rigorously evaluated. Not even Tanenbaum would object, I trust, to evaluating these interventions on the basis of a defined end point or outcome. As long as it uses proper scientific and statistical methods, outcomes research adds to available information and should benefit medical practice.
Why then does such research provoke resistance, when randomized clinical trials do not? One reason may be that clinical trials take place in controlled settings, whereas outcomes research is based on actual practice and is perceived as a threat to professional autonomy. A second reason may be that clinical trials are generally conducted by physicians to improve professional knowledge, whereas outcomes research is often sponsored by lay entities to increase economic value and is thus perceived as allowing concern about cost to intrude on clinical decisions.
Tanenbaum feeds on these fears but makes two fundamental mistakes. The first is to ignore the relation between cost and care. Cost is a reality of medicine (and of life). If outcomes research is not used to help contain costs, other methods will be. Traditional rationing schemes rely on government to enforce budgets and constrain technological expansion and capital investment. It is ironic that physicians who would otherwise oppose external controls support centralized rationing because, superficially at least, it appears to absolve them of responsibility for considering cost when they treat patients.
Tanenbaum's second error is to assume that the clinical information derived from outcomes research will be applied without the participation of physicians. Information on outcomes empowers (and forces) physicians to manage the process by which health care is delivered. For reasons I have never understood, the medical profession prefers to regard health care as a series of individual doctor-patient encounters subject to purely external constraints, rejecting outright the “theory of the firm,” which holds that complex systems benefit from systematic internal management. This myth of individual encounters belies the complexity of medical problems and the interdependence required to solve them, including coordination of services and sharing of data. It also seems to lead physicians (and commentators such as Tanenbaum) to reject the possibility that collective information may be useful information.
1 ReferencesWilliam M. Sage, M.D., J.D.
400 S. Hope St., Los Angeles, CA 90071-28991
Tanenbaum SJ . What physicians know. N Engl J Med 1993;329:1268-1271
Full Text | Web of Science | Medline
To the Editor:
Someone needs to defend the outcomes movement from the beating it received from Tanenbaum1,2. My concern is that unfortunately, you will not receive an avalanche of letters protesting her discourse. Physicians are naturally fearful of the perceived threat to autonomous practice posed by outcomes research. Dr. Tanenbaum's article panders to this fear.
Dr. Tanenbaum asserts that physicians and other professionals who are proponents of outcomes research see it as a panacea. This statement is incorrect. Rather, we in the outcomes movement are resurrecting, developing further, and testing methods that, like research in the basic sciences, will be a useful addition to the clinician's arsenal, not a replacement for it. The conflict between the outcomes movement and physicians' “personal knowledge” that Dr. Tanenbaum constructs exists only when the outcomes movement encounters insular and introspective clinical practice.
Dr. Tanenbaum makes an important point with regard to the value of physicians' intuition and experience in clinical decision making. She cannot make this point correctly or give it intellectual weight, however, by invoking Polanyi's concept of personal knowledge. She treats physicians' personal knowledge as if it were separate from impersonal (statistical) knowledge but similar to it in being somehow measurable and variable in degree from person to person and from profession to profession. That is a misuse of Polanyi's idea. Polanyi describes personal knowledge as both the process and the product of human understanding interacting with reality3. According to this definition, personal knowledge is something we all have, whether we are politicians, mechanics, schoolteachers, outcomes researchers, or physicians, and among us all it is not measurable and does not vary in degree.
This concept does acknowledge that some of us are better skilled at processing reality than others. The point Tanenbaum seems to make is that in combination, the physician's intelligence, intuition, and experience are a better processor of reality than is outcomes research. We in the outcomes movement agree, but point out that the processing of reality will improve if physicians add outcomes research to their combined skills. Furthermore, what physicians should know is that in the broad view of their role in society, they are responsible for exploring any and all methods that hold out the prospect of improving health outcomes.
3 ReferencesCharles B. Cangialose, Ph.D.
Thomas Jefferson Health Policy Institute, Charlottesville, VA 229011
Tanenbaum SJ . What physicians know. N Engl J Med 1993;329:1268-1271
Full Text | Web of Science | Medline2
Kassirer JP . The quality of care and the quality of measuring it. N Engl J Med 1993;329:1263-1265
Full Text | Web of Science | Medline3
Polanyi M. Personal knowledge: towards a post-critical philosophy. Chicago: University of Chicago Press, 1958.
Author/Editor Response
Dr. Tanenbaum replies:
To the Editor: Both Dr. Sage and Dr. Cangialose fault me for a critique of outcomes research I did not make. Rather, I explicitly acknowledged the usefulness of statistical analysis in evaluating medical care. I reserve my critique for the outcomes movement, the organized efforts of one research community and its champions to gain special privilege for statistical evaluation, to consider it the only true evidence of medical effectiveness, and to predicate an accountable health care system on physicians' adherence to norms of practice derived from outcome studies.
Is there such a movement? I believe a serious reading of the health policy literature1 will provide evidence not only of its existence but also of its energy and influence. Some participants in the movement, moreover, are less reticent than Sage and Cangialose in arguing that statistical evidence of effectiveness is ideally superordinate to other forms of medical knowledge. Eddy and Billings, for example, took the position in 1988 that high-quality medical care would result from a two-stage process of controlled study and guideline enforcement2. The federal government's “effectiveness initiative”3 reflects this position, as does the structure of the federal Agency for Health Care Policy and Research, created in 1989. One British cardiologist is unabashed: “Clinical freedom is dead. . . . Medical care must be limited to what is of proved value, and the medical profession will have to set opinion aside”4.
In their efforts to depict me as playing to the fears of venal or pusillanimous practitioners, my critics have shown their hands. Dr. Cangialose and I do not disagree about Polanyi except to the extent that Cangialose disregards the physician's personal knowledge of the individual patient. Dr. Sage looks to outcomes research to contain costs; I can only hope this implies a belief in its ultimate veracity.
4 ReferencesSandra J. Tanenbaum, Ph.D.
Ohio State University College of Medicine, Columbus, OH 432101
Gray BH . The legislative battle over health services research. Health Aff (Millwood) 1992;11:38-66
CrossRef | Web of Science | Medline2
Eddy DM ,Billings J . The quality of medical evidence: implications for quality of care. Health Aff (Millwood) 1988;7:19-32
CrossRef | Web of Science | Medline3
Roper WL ,Winkenwerder W ,Hackbarth GM ,Krakauer H . Effectiveness in health care: an initiative to evaluate and improve medical practice. N Engl J Med 1988;319:1197-1202
Full Text | Web of Science | Medline4
Hampton JR . The end of clinical freedom. BMJ 1983;287:1237-1238
CrossRef | Web of Science | Medline
- Citing Articles (3)
Citing Articles
1
Laurent G. Glance, Turner M. Osler. (2001) Comparing outcomes of coronary artery bypass surgery: Is the New York Cardiac Surgery Reporting System model sensitive to changes in case mix?. Critical Care Medicine 29:11, 2090-2096
CrossRef2
John R.A. Rigg, Konrad Jamrozik, Paul S. Myles. (1999) Evidence-based methods to improve anaesthesia and intensive care. Current Opinion in Anaesthesiology 12:2, 221-227
CrossRef3
James B. Semmens, Michael M.D. Lawrence–Brown, David R. Fletcher, Ian L. Rouse, C. D'Arcy J. Holman. (1998) THE QUALITY OF SURGICAL CARE PROJECT: A MODEL TO EVALUATE SURGICAL OUTCOMES IN WESTERN AUSTRALIA USING POPULATION-BASED RECORD LINKAGE. ANZ Journal of Surgery 68:6, 397-403
CrossRef
