Under My Skin: Where's the Evidence?


We physicians are encouraged to practice evidence-based medicine whenever possible. This is a good idea, even if using evidence is not always applicable or even possible. Still, many treatments that are traditional or make sense turn out to be ineffective, or at best unproven.

But what if everybody had to act based on evidence, for instance, the program administrators who increasingly run our professional lives? I offer two examples: iPledge and ICD-10 codes.

A recent editorial reviewed the 5-year history of the iPledge program for patients taking isotretinoin (J. Am. Acad. Dermatol. 2011;65:418-9). Dr. Mary E. Maloney and Dr. Stephen P. Stone noted that iPledge has eliminated some of the software glitches that made our lives miserable at first. But has it succeeded in its stated purpose: to limit pregnancies among women taking the drug? Evidence shows that it has not.

The authors cited a recent study showing that, "in a large managed care organization, pregnancies have not decreased with the iPledge system." The reasons for this are easy enough to figure. No number of negative pregnancy tests will prevent birth control pills from sometimes failing, or stop patients from forgetting to take them.

Will the administrators of the program respond to this evidence and change or eliminate iPledge? You can hold your breath, but forgive me if I don’t join you.

Or take ICD-10, the new disease classification system, scheduled to go into effect October 2013, which will expand the number of diagnoses from 18,000 to 140,000.

ICD-10 was recently lampooned in a Wall Street Journal article by Anna Wilde Mathews ("Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way," Sept. 13, 2011). Her article pointed out interesting new disease categories, such as V91.07XA, "burn due to water-skis on fire." And, W22.02XA, "walked into lamppost, initial encounter," and W22.02 XD, "walked into lamppost, subsequent encounter." There is even a third code for "walked into lamppost, sequela."

The comments left online accompanying her article offered even more hilarious ICD-10 examples, such as T63.111A, "Toxic effect of venom of Glia monster, accidental (unintentional), initial encounter," another for the second encounter, and a third for sequela, and "Toxic effect of venom of Gila monster, intentional, initial encounter," (plus second encounter and sequela).

Such stuff is beyond parody, but it points to a serious idea that pervades our technocratic society: the fetish that more information is better. Financial firms tout their original, fundamental research that generates mounds of information and helps their portfolios shrink right along with rest of the market. IBM advertises that its "smarter planet" will give doctors up-to-the-minute information from the burgeoning literature, so they can make better diagnoses.

Right. I’ll call Watson the computer to help me diagnose my next 50 patients with acne, warts, psoriasis, and eczema.

You will fault me for being too cynical. Perhaps more information can be useful, at least sometimes. But my question is: Where is the evidence?

iPledge and ICD-10 are not random disasters of nature like tornadoes and tsunamis. They are the conscious acts of human ideas. At some point in real time, these living humans met around tables in actual rooms and decided that tabulating data on Gila monster bites (first episode, second episode, accidental, and intentional) would make the world a better place. I picture this room in a hospital OCD ward, but possibly not. Wherever they worked, the people responsible decided this because it made sense to them.

As with iPledge before it, instituting ICD-10 is a nontrivial act. Much anguish will be suffered, and much time, effort, and treasure will be spent to implement it. And why all the suffering and expense? Because doing it "makes sense."

Radical mastectomy for breast cancer once also made sense. So did forequarter amputations for melanoma of the ankle. That’s why we collect evidence and, now and then, apply it.

I have no illusions that my objections will influence any policy makers to reconsider their positions. Who’s going to make them? Their conviction that more information is better is just too strong.

I actually expect to live through a few more of these bureaucratic initiatives before I am done in by some rampant Gila monster who has a bad day, gets lost, and decides to bite me. Intentionally.

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