That is why, for example, the average internist can describe the branching patterns of the major coronary arteries but not the primary clinical trials assessing how much, if at all, various cholesterol-lowering agents cut heart-attack risks. Or, for that matter, whether the trials were soundly conducted. Yet in real practice, diagnostic puzzles are rare, and knowing the molecular basis of an illness does little good. Instead, children see pediatricians for ear infections, diarrhea, and attention-deficit disorders. Adults see internists for high blood pressure, diabetes, and chronic pulmonary disease. Filling the training vacuum, an unregulated, for-profit industry of information peddlers is emerging to interpret clinical trials and guide treatment.
These groups essentially write CliffsNotes for doctors, and their influence on medical care cannot be overstated, though it's largely invisible to consumers. The most widely used service is UpToDate.com, a private-equity-backed, subscription-only Web site that, according to some research, is accessed by half the clinicians at hospitals affiliated with Harvard Medical School at least five times a week. Eighty-seven percent of U.S. teaching hospitals subscribe to it. On the site are thousands of recipelike entries on everything from toddler ear infections to drug therapy for heart failure. UpToDate.com has become the cookbook for medical treatment. No professional primary-care medical association, like the American Medical Association or American Academy of Pediatrics, has created anything like it.
To its credit, this site is subscriber-funded and refuses advertising, unlike rival sites like Medscape and eMedicine. But there's no guarantee it'll stay that way, especially if it is sold or goes public. And while the overall quality of information is quite good, the treatment guidelines tend to favor medications over modifying behavior and lifestyle, are not vetted by any government or other professional association, rely a lot on the personal views of the one or two authors of each recipe, and rarely include any cost-benefit analysis. Fundamentally, by neglecting treatment, doctors have outsourced it to private contractors who don't answer to any authority. (This is why drug companies can launch misleading marketing campaigns without a unified voice arguing on the side of the data.)
Even if perfect treatment guidelines were to appear magically, it takes a lot of work to teach doctors to follow them. Consider ear infections in children, which are vastly overtreated with powerful antibiotics. In 2000, a group of Boston researchers created an ambitious three-year program (using sociological methods used by missionaries to score religious converts) to educate local pediatricians about proper ear-infection treatment. They explained how to talk to patients, control symptoms without antibiotics, and create educational handouts for patients. They taught doctors what they should have learned in medical school and, as reported in Pediatrics this year, substantially cut antibiotic use. The only sticking point is that it all took a big investment of time and money.
Treatment neglect has big consequences beyond ear infections. Medical errors may claim almost 100,000 lives each year, often from basic skills like poor handwriting on prescriptions. In her book, Overtreated, Shannon Brownlee explains how ignoring treatment has led to odd discrepancies in medical care; for example, some towns in Vermont had tenfold higher rates of pediatric tonsillectomy than others, despite having the same kinds of patients.
Refocusing doctors on actual treatment, instead of pointy-headed diagnostic puzzles, will take serious effort. In the meantime, patients should ask a simple question: "Can you describe the evidence for my treatment?" For better or worse, the answer will tell you a lot about the care you're getting.