Should Medical Associations Preach Evidence Basis?

Evidence basis gets much attention. Unfortunately there is much opinion and assumption that buries the evidence. The pathway to becoming a leader in an association is paved with areas believed to be important with or without evidence basis. Associations are prone to point out the need for evidence basis, but they may be the ones that should be improving evidence basis across leaders, staff, and media.

The popular media passed around is a great source for assumptions. Unfortunately works published in major journals need a great deal of improvement also.


AAFP has a number of areas for improvement regarding evidence basis

1. Maintenance of Certification is supported despite lack of evidence
2. Pay for Performance and derivatives are supported despite lack of outcome improvement in major reviews
3. Pay for Performance is supported despite the consistent evidence to lesser payment for those serving Americans left behind (where family physicians are 3 times more likely to be found)
4. AAFP should be exposing the lack of significant health outcomes improvements from a number of clinical interventions
5. AAFP should maintain a constant focus on the personal, community, social factors that are 60 - 70% of health outcomes. This also leads to a choice between outcomes improvements for most Americans or protection of the academic/clinical focus/status quo.

The above should be reflected in all media, leadership postings, and staff activities. Pay for Performance fails in evidence based reviews

• Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting. 
• and in Readmissions Penalties That Fail to Indicate Quality or Predict Outcomes   "What we see here is that the 30-day readmission does not really track with the quality of care that patients get and also does not track with long-term outcomes." Even worse the penalties discriminate. Only Medicare can find a way to pay even less to those least paid who face the great challenge of caring for the most complex patients with the least local resources. Stop the costly carnage of pay for performance!

Opposing the Tyranny of Health Care Research

In addition AAFP should prioritize a return to evidence basis. There should be movement away from jump on the bandwagon acceptance of research methods and findings that were exposed as defective 100 years ago. Dr. Jha noted below has been consistent in such work.

"What is the central tendency of a distribution but a lazy generalization? The aggregate, the mean, is wrong about everyone but the few closest to the mean, yet is so revered because we mistake the aggregate for the truth. The tyranny of the aggregate is the most extraordinary tyranny of our times. The aggregate is built by people who vary, yet it imposes itself on the individuals, the very variation which creates it. It literally bites the hands that feed it." SAURABH JHA, MD (associate editor with The Health Care Blog)

More at The Tyranny of Health Care Research

Please No More So-Called Primary Care Solutions

As a consideration AAFP should also be critical regarding promotions of various training interventions. There has been some tacit understanding of "The Dean's Lie" regarding medical school leader claims of primary care result that are not really primary care, but AAFP has not remained critical in an evidence-based way.


There have long been claims of overall improvements across MD DO NP PA FM training in areas such as primary care, health access, rural practice, or care where needed. But all fail due to inadequate financial design.

Training interventions can only rearrange the initials and names but not change inadequate delivery capacity. How many decades of watching this happen across entire states should be tolerated before the top priority

As a cushion for the claim of inability to result in the necessary increased capacity, note

1. The substantial increased cost of delivery via new regulations and certifications that can only make the financial design and capacity worse.
2. 30 - 50% greater than average population growth in 2600 lowest physician concentration counties over the past 5 decades - not surprising given the inability of more Americans to pay for housing and other basics where workforce, property values, and cost of living are most concentrated
3. 2600 lowest concentration counties with higher concentrations of elderly and complexity. 
4. This is a massive increase in demand where 40% of Americans fall further behind by designs that fail for generalists and general specialties that are 90% of local services in these counties. 
5. Compare this to 1100 zip codes with 10% of the population that have 45% of physicians and greater than 50% of health spending - leaving little for most Americans by designs that concentrate the most lines of revenue and the highest reimbursements in each line.
6. Fewest remaining in primary care positions, particularly family practice positions across all sources, as the financial design rewards more new specialties with more added in each specialty

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Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

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