The key finding from focus groups, interviews, and the online survey is that there is a fundamental disconnect between the central tenets of evidence-based health care and the knowledge, values, and beliefs held by many consumers. For health care experts, variation—in quality among health care providers, the evidence base regarding therapies, and the effectiveness and cost-effectiveness of treatment options—is a well-established fact of the health care delivery system, documented extensively in the published literature and well understood after years of careful study. Yet such concepts are unfamiliar to many Americans and may even seem threatening, to the extent that they raise unwelcome questions about the quality of medical care that people receive.The majority of consumers believe that all care meets minimal quality standards, that more care means higher quality care, that newer care is better care, that treatments costing less are inferior, and that medical guidelines "represent an inflexible, bargain-basement approach to treating unique individuals."
The news for health reform could hardly be worse! Reformers and consumers are talking different languages - the language of rationality and the language of faith. But the findings shouldn't surprise us. Since the time of Hippocrates we humans have schooled ourselves into a trusting worship of the healers. That faith helps us ward off the terror engendered by our awareness of vulnerability and mortality.
At the level of clinician-patient interaction, it's possible to bridge the gap. I frequently said to patients suffering from depression some version of - "Of course none of us can be a hundred percent certain about the future...but that said, I'm sure we can make this depression go away." Or, as a wise and caring oncologist said to a dear friend of mine at the point when the chemotherapies he was master of had come to an endpoint - "X, the best thing I can do for you now is to give you a hug" - a "treatment" he promptly delivered!
Consumer skepticism about evidence-based medicine reflects our effort to deal with mortality, not stupidity. To effect change health care professionals and policy leaders need to learn how to explain the importance of practice variation, comparative effectiveness research, and all the other wonky concepts those of us concerned with health reform are so fond of, in ways that respect our human need for solace in the face of finitude and vulnerability.
I've often used the example of how the wise oncologist dealt with my friend with medical students. He applied evidence-based technologies in prescribing therapies that prolonged my friend's life. But when life prolongation was no longer possible, he remained in the role of reassuring healer and provided a different form of evidence-based practice - laying on of hands in the form of a hug, and a commitment to be part of my friend's life to the end.
Wise clinicians understand and apply the aphorism "To cure sometimes, to relieve often, to comfort always." For the public to develop more belief in evidence-based medicine it will have to develop a stronger faith that our health system will "comfort always."