A long-ago football injury and the case for better evidence-based care

[Previously published by Hospital Impact]

If you have played football at any level, or perhaps if you have a fantasy football team and all of a sudden care about sports-related injuries, you are probably familiar with the term “Unhappy Triad.” The unhappy triad is a severe knee injury involving the full or partial tears of the Anterior Cruciate Ligament, the Medial Collateral Ligament and a tear of the Medial Meniscus.

Back in 1984, while playing football in college, I decided to do one (or two) better. In addition to tearing the two ligaments and the cartilage listed above, I also tore the Posterior Cruciate and Medial Collateral ligaments. My orthopedic surgeon at that time said, “You literally have nothing holding your knee together.” Well, there goes my dream (pipe dream that is) of joining the Dallas Cowboys as a slot receiver.

Why do I tell you this? In 1984 the surgery performed on my knee was the standard of care based on the evidence at that time—evidence-based medicine. By 1988, this same surgery was no longer the standard of care and according to my new surgeon, was now considered malpractice. Five, six or seven knee surgeries later (I lost count), I believe we finally have it right, but the damage has been done as has the cost to the system been accumulated. Clearly new information has debunked previous research outcomes that led to the earlier evidence-based standard of care.

This all came to mind as I recently read the results from the study shared in the journal Science, “Estimating the reproducibility of psychological science.” This study, which focuses on psychology research outcomes, notes: “Scientific claims should not gain credence because of the status or authority of their originator but by the replicability of their supporting evidence. Even research of exemplary quality may have irreproducible empirical findings because of random or systematic error.” It highlights that only 25 percent of the social psychology experiments and only 50 percent of cognitive psychology studies were able to be replicated, meaning that for all the others, “the originally reported findings vanished when other scientists repeated the experiments.”

Why is this important as we seek to improve the health of our patients, families and communities? Because similar to the intervention for the unhappy triad, which was eventually proven dangerous, mental health interventions are based on the “evidence” stemming from psychology research outcomes. And based on this study, there is “a 64 percent failure rate even among papers published in the best journals in the field,” John Ioannidis, professor of health research and policy at Stanford University, between the social and cognitive psychology studies, told The Guardian. And yet, interventions that affect patients, families and communities remain reliant on these outcomes.

But this is not new. As I shared back in the 2011 piece, “Reliable clinical research is missing piece of healthcare reform puzzle,” the Institute of Medicine has claimed that only about half of medicine is based on valid science. Ioannidis also noted at that time that 80 percent of non-randomized studies and 25 percent of randomized studies are wrong. And again, healthcare treatments continue to become the standard of care based on these studies. We can do better.

As research improves, we healthcare leaders in the meantime must develop new systems to better position clinicians, patients, families and communities to optimize the challenging research outcomes within this broken system.

And, in fact, in the 2011 piece referenced above, I highlight a process to do so that also leverages relationship-centered care principles, which I update here:

At a minimum, we need to ensure the following elements of a new healthcare paradigm are in place:

  • Physicians must have easy access to clinical research experts, with all biases clear and understood–noting there is always bias.
  • Physicians must be educated on how best to critically review, assess and analyze the clinical research for themselves.
  • Physicians must have the time to invest in assessing the latest research.
  • Physicians must have the time and space to discuss the research data and resulting varied treatment options with trusted colleagues and experts.
  • Physicians must have the opportunity to leverage the now understood clinical research and discuss a challenging patient situation and/or a “best practice” in a safe setting with trusted colleagues.
  • Physicians and patients (and families when appropriate) must have the time and space to develop real relationships and trust where information flows freely and where whole stories are told, heard and understood.
  • Physicians and patients (and families when appropriate) must have the time and space to get to the root cause of a symptom and co-create a treatment plan that is based on accessible, valid, clear, bias-understood and trusted clinical research outcomes and that is best suited for the specific patient.
  • Outcome goals and metrics for each specific patient must be developed together by the physician and patient (and families when appropriate), assessed regularly, and the treatment approach modified as appropriate.
  • Physicians must be compensated appropriately for all the above.

We do not have the luxury of waiting for the greatly improved research model. Our patients, families and communities are being harmed now. It is time to lead, to serve and to make a difference understanding all the current constraints. We can do this … together.

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