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Journal of Health Politics, Policy and Law 26.2 (2001) 439-446



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Commentary

The Politics of Evidence-Based Medicine

Marc A. Rodwin
Indiana University


The impetus for these essays on evidence in medicine and law is commonly called evidence-based medicine: the movement to evaluate the safety, effectiveness, and cost of medical practices using tools from science and social science and to base clinical practice on such knowledge. Evidence-based medicine is portrayed as an alternative to medicine based on authority, tradition, and the physician's personal experience. The role of politics is rarely mentioned. When discussed, politics is portrayed as what evidence-based medicine will avoid.

Rational evaluation of evidence plays an important role in medicine. However, it is not an alternative to medical politics. Rather, evidence is a tool for institutional control and policy argument. Today evidence-based medicine is used to oversee individual physicians and the practice of medicine. It thus helps to alter the balance of power among doctors, payers, and patients. Changing medical practice requires the development of political, legal, and medical institutions that oversee medical care. Promoting medical practice based on evidence will therefore necessitate more, not less politics. [End Page 439]

The Significance of Evidence-Based Medicine

Until recently physicians practiced medicine based primarily on their medical training, individual experience, and local custom. Few people understood what doctors did and medical work was shrouded in secrecy. Patients had little access to information about medical options or the performance of physicians. Payers also had little information and relied largely on physicians to exercise their best judgment. Doctors knew about their colleagues' work by direct observation or reputation, but there was little in the way of external assessment or control over medical practice outside of informal professional self-regulation. These conditions promoted physician autonomy and sovereignty.

Over the past half-century this situation has changed. Payers have sought to control spending. Patients have sought greater control over their treatments. Both patients and payers aimed to improve the quality of medical care. Physicians and other providers could accept the goals of payers and patients in principle. However, achieving these goals required changes in physician behavior and redistribution of income. Cutting costs, for example, requires reducing the income of physicians, hospitals, and other providers as well as changing the way medicine is practiced. Such changes do not come about without political struggles. In this fight, physicians traditionally possessed significant clout: their authority based on medical expertise. Doctors decided what was medically appropriate with little need to explain or justify their decisions.

Over the past quarter century, managed care organizations (MCOs) have shifted power away from physicians to payers. MCOs required, in one way or another, that doctors and medical institutions change their conduct. Along with new institutions there have arisen new professionals, a class of managers whose job it is to rationalize medicine. They evaluate, oversee, and control medical practice, particularly the conduct of physicians.

Evidence-based medicine helps promote this shift in power and facilitates the work of medical managers. To begin with, evidence-based medicine reduces the discretion and autonomy of physicians. While in the past the authority of doctors prevented questioning of their clinical choices, with evidence-based medicine, payers and managers can ask physicians to justify their decisions, thereby reducing the clinical discretion of doctors.

Moreover, when relying on evidence-based medicine, clinical choices [End Page 440] are not justified based on clinical insight, medical training, or personal experience. Instead, they are based on data from journal articles in medicine, epidemiology, and economics, which rely on such analytical techniques as random clinical control trials, multiple regression analysis, and cost-effectiveness analysis. These methods don't require a medical education and place nonphysicians trained in social science, science, or public policy analysis on par with physicians. 1 Relying on such studies breaks the lockhold that the medical profession traditionally has had over judging medicine.

Furthermore, evidence-based medicine has enabled payers, purchasers, and governmental authorities to use their financial clout to alter the practice of medicine. Traditionally doctors defined the standard...

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Additional Information

ISSN
1527-1927
Print ISSN
0361-6878
Pages
pp. 439-446
Launched on MUSE
2001-04-01
Open Access
No
Archive Status
Archived 2005
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