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Send to a FriendIt has been more than 20 years since Dartmouth's John Wennberg demonstrated significant geographic variance in patterns of clinical practice. In the ensuing years, technology has vastly changed the speed and efficiency of information dissemination. Journals and textbooks are available on-line, MEDLINE searches are done from one's office or home. Our professional societies' meetings are broadcast and archived on the web. Our colleagues are available to us by email from anywhere in the world. Witness the vast amount of information available on our very own CTSNet. Our patients, too are becoming ever more sophisticated and knowledgeable. A significant number of them come to an appointment armed with information gleaned from the Internet, some of it helpful and some not. As patients become more informed, the dynamic of the doctor-patient relationship is changing, becoming less paternalistic.
Despite these incredible advances in information technology, there is still tremendous variation in the practice of medicine, and certainly in the practice of general thoracic surgery. Even as more and more information becomes available, many of our colleagues continue to ignore evidence-based practice, and base treatment decisions on personal bias or anecdotal evidence. While personal experience and judgment have a role in clinical decision making, when those decisions and recommendations fly in the face of scientific data, our patients suffer. I practice in a very sophisticated medical community, yet many of my colleagues are either unaware of, or choose to ignore, the literature regarding the treatment of Stage 3A non-small cell carcinoma of the lung, superior sulcus tumors or esophageal carcinoma. Some of these same colleagues refer few, if any, patients for participation in such important clinical trials as S9900. What is most distressing is that this takes place at major academic medical centers, not small community hospitals. Wennberg and others, such as Harvard's Donald Berwick, have demonstrated that the care patients receive depends in large measure on who happens to be treating them.
What is to be done? Certainly, we physicians cherish our autonomy after years of training in our chosen specialty. Some disease states do not have a single, best treatment option. There is room for honest differences of opinion, when those differences have a scientific basis. However, there is a large body of scientific literature that can and should guide our treatment of patients, and there is often a clear "best practice" for a given diagnosis. We can and should practice evidence-based medicine. Perhaps it is time that our professional societies assume responsibility for compiling, disseminating and promoting those best practices, so that government or third party payers do not assume that role. It is we who must set the "standard of care". If we do not do this, who shall?