Practicing Evidence-Based Medicine (EBM) in a Cash-Based World

In this episode I discuss what it’s like practicing evidence-based medicine (EBM) in a cash-based environment including

• Common assumptions doctors and patients make about cash-based practice
• Why EBM is critical to the future of DPC
• Top reasons for falling down the slippery slope to quack-town
• How do talk to your patients about EBM and why you do it

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Transcript

Sonia Singh MD 0:01

Hey doctors. You're listening to the Micropractice Mama Podcast, a podcast for women physicians who are striving to practice primary care sustainably and creatively with autonomy, authenticity, and joy. I'm your host, Sonya Singh, internist, PCP, and proud mother of two human babies, one for a baby and one. Life-changing micropractice. I wanna empower you to push past whatever is holding you back and make the leap to launching a practice that aligns with your values and priorities, and finally allows you to take care of your patients, your family, and yourself in the ways that you want and deserve. Are you ready to make the leap? Let's do it. Hey doctors, I've got an awesome episode for you today on one of my favorite topics, one of the hills I will die on, which is evidence-based medicine. I feel like I should make an entire episode on all the hills I will die on.'cause I say that about several things over and over, but I think this is gonna be a controversial episode. I'm sure I'm gonna get some, strongly worded emails after this, but again it's a hill I'm willing to die on. And I feel really passionately about this subject specifically in DPC. Because I think that when physicians think about cash-based practice, there's often a lot of assumptions and biases that come along with that, especially physicians who are academically trained, which I was. And I had a lot of these biases initially, and I wanted topel some of those myths. And I wanna emphasize the importance of people doing DPC, practicing evidence-based medicine, because I think it's critical to the future of DPC. And I also wanna share a little bit with you about how I talk to my patients about evidence-based medicine because. I do think, just as doctors have their own assumptions about what a cash-based practice will offer, patients also have similar assumptions sometimes, and that can be a challenge when you're first entering the DPC space. So in this episode, I'm gonna cover what is evidence-based medicine? What does that even mean? Why does it matter? I'm gonna review a few of the common criticisms of evidence-based medicine that I've heard. I'm gonna share sort of my take on EBM and why I don't think those criticisms hold up. I'm gonna talk about why I think practicing EBM is critical to the future of DPC. And then I'm gonna talk a little bit more about how to be successful in DPC. With just good high quality evidence-based primary care and, how do you avoid falling into this trap of offering gimmicks and sort of snake oil basically type treatments to attract people to the practice. Okay, so let's first talk about what is evidence-based medicine? I'm gonna give you a definition from Stat Pearls which is like a NIH resource. So they say Evidence-based medicine, or EBM uses the scientific method to organize and apply current data to improve healthcare decisions. Thus, the best available evidence is combined with the healthcare professionals clinical experience and the patient's values to arrive at the best medical decision for the patient. Who could object to that. That sounds wonderful. That sounds great. What I see a lot of people who honestly people who do things that I would not consider evidence-based medicine often, what their criticism of. EBM is a few things. One, they'll say what you think is EBM or what often is considered the standard of care in evidence-based practice is often not based on a huge amount of, scientific research. It's based on actually something very limited, but we've just been doing it for so long that it's become the standard of care and it falls into that EBM realm, even though the evidence is lacking and I think they're right. I think that's true in some cases. And for instance, right now I'm doing it feels like a significant amount of perimenopause and menopause care and, I follow the guidelines of the Menopause Society. But even following those guidelines, I acknowledge that for some of the things I'm doing, the level of evidence. That, those decisions are based on is nowhere near the level of evidence for the way I would manage diabetes or heart failure. Like it's a totally different pool of information that you're dealing with, but that is the best available evidence. That is the best available science that there is, and I'm following guidelines by the experts in this field on this topic. I think the time when you get in trouble doing non-evidence based medicine is really when. People are doing something that is actually contrary to what the standard of care is, or, has explicitly been, disproven or, there's like a few studies that have shown benefit for something, but there's 10 or 20 that show that, there's no clear benefit, and when you're continuing to do that thing. To me, that is really what I'm talking about when I'm saying non-evidence based medicine. So anyway, I will acknowledge that yes, there are things that kind of fall within the scope of standard of care that, maybe have limited e evidence, but our job is to use the best available and sometimes that's the best available. The other thing. That you often hear people say about EBM is but, there's publication bias, there's bias among the societies that make these recommendations. There's bias everywhere, basically. That's also true. Science does not exist in a vacuum. There is, there are many types of bias and, I think publication bias is probably one of the biggest examples of this. There's of course going to be a lot of, positive studies on. Drugs that are very lucrative for pharmaceutical companies to develop and promote and, find new indications for, there's not as much incentive to study the benefits of a carrot or, the natural home remedies that there's no ability to patent or make money from. So yes there's certainly bias. There's bias in literally everything. But I don't think that means that we then discount, what appears to be the best available evidence and the opinion of experts. Yes, we acknowledge that it's not going to be 100% objective all the time, but I don't think that's a reason to say we've gotta throw all that out the window and analyze everything ourselves. And then lastly, and I think this is probably one of the most legitimate ones, and one of the reasons why it is so important for all of us to continue our, CME and to stay, in touch with what's happening in our fields is just that there is this lag time before something that is clearly showing up in the research gets translated into. Official algorithms in society guidelines and U-S-P-S-D-F recommendations and certainly insurance coverage. And so I think, being in tuned with what's happening in your field and with, the latest research and all of that is, hugely valuable and important as part of your, clinical. Competence and expertise. But again I think jumping the gun and saying this study came out so I'm changing my practice tomorrow. May not always be, a decision that you should be making on your own. Overall though my, my biggest problem when people start doing. Non-evidence based medicine. They would probably say, oh, but there's evidence. But, a study in 10 rats or a study in even 10 humans is really not evidence. So my biggest beef with this is that to me, it represents a certain type of intellectual arrogance. Let me explain why I think that, so let's use an example. Let's say a patient comes to me and they're asking me about some intervention for PCOS, aol, whatever, anything some intervention for PCOS. And they're like what do you think of this? So let's say I'm a really good doctor. I've got the time on my hands, I've got the bandwidth. I go to PubMed, a Google Scholar, or I like look up the, I look up some studies on this. I review them myself. I. Critically analyze them. And then I come to some conclusion or opinion that I'm gonna share with the patient. Now, I think most of us would agree that me compared to, let's say, an endocrinologist, my friend who's an endo who has spent three extra years learning about hormonal pathways and becoming an expert in this field, let's say she reviews the same exact papers that I reviewed. I think we can all agree that her. Grasp of that material, her understanding of the nuances, her ability to critically appraise that is probably going to be better than mine. Your ability to analyze that information is not purely just based on your intellect alone. It also is based on, your fund of knowledge and your clinical experience that you bring to that, the context you bring to that paper. Now let's compare that friend who's an endocrinologist, let's compare her understanding of this paper or this data to an endocrinologist who has an entire clinic focused on treating women with PCOS. Wouldn't we agree that person probably has a better grasp of, that data and that research than you know either of the other two of us do? I think we would, and that's basically how you arrive at deferring some of these decisions and guidelines and, treatment algorithms to major societies. And sometimes those are expert opinion and not really based on, huge meta-analysis. These or whatever, but that's the best we have, right? I think we can all agree that that those people are more qualified to make those judgements and those algorithms than, an individual internist or family medicine doctor who's out there treating this. To me it seems like a no-brainer, to defer that judgment. But I, I think there's a certain, overestimation of your own abilities involved in just saying Yeah I'm gonna read those ivermectin studies myself, and I came to the conclusion that, this makes a lot of sense. Again, I'm not saying that we should just be totally checked out and not be paying attention and not be reviewing the primary literature and, not be looking at the quality of these studies ourselves. But the reality is that most of us in full-time clinical practice would not have the time to do that for every decision that we make, which is realistically why we have to follow these, guidelines released by major societies and. Trust the opinion of, people who devote their lives to each of these different, clinical topics. So that's basically my take on EBM. Now, let me share with you why I think EBM doing EBM is so deeply critical to the future of DBC. If you are in DPC already, or even if you're just thinking about it and floating the idea to people, you are likely noticing that a lot of people in the medical community, when they hear cash based practice, a lot of them will not know what DPC is. They won't be familiar with the model. They won't have met any DPC doctors. They won't have seen any DPC practices. So in their mind, when they hear cash, they start thinking, aesthetics, IV vitamins, random B12 shots, weight loss pellets, like that is, I once told a plastic surgeon who was working in the same space as me, I was like, oh, yeah I'm doing this thing direct care, it's membership based. And he was like, oh, okay, cool. Pellets. And I was like. No. And he's aesthetics. I was like, no. Weight loss. And I was like, when it's medically indicated. And he just, he could not wrap his head around this idea that I was doing a cash-based practice and just doing primary care like that seemed like a very strange foreign concept, and that's sad. That's very sad. But I will tell you that I had a lot of the same biases. I remember my friend joined. What I now know to be a DPC pediatric practice when I was just finishing up residency, and I remember her telling me like, oh, it's great. Like they're gonna bypass the insurance. And, she's free to make the decisions she wants. And I was just listening to all this and I was just like, yeah, she's probably gonna sell you snake oil. She is gonna sell you supplements and nonsense, and she's gonna tell you to do things that are not covered by insurance because they're not medically indicated. And I was so firm in that belief. Didn't even give it a chance. And I think a lot of doctors still have that set of beliefs about anything that is cash based. And, they lump everything together with like med spas and kind of predatory wellness places and, just, they think it's all one big entity. And I really want DPC to carve out its own lane and to be, viewed by both patients and physicians as different. One of the things I see really commonly in some of the DPC groups is. Somebody will open a practice and sometime in the first six months to a year, they'll start feeling a little nervous about their growth or feeling like, gosh, I'm just not getting patients. I'm not, I haven't broken even. Or they start getting nervous, right? They start having that panic. Then they start saying maybe I should just offer some IV vitamins, or maybe I should just do a little compounded semaglutide, or maybe I should just, start offering aesthetics and I think, in their mind some of them will be telling themselves it's, if it's not harming the patient, maybe that's okay. What's wrong with that? I would argue that any intervention even the most. Benign thing that is not medically indicated and that have not been clear to the patient about whether it's medically indicated or not could cause a potential harm. Anytime you break the skin infection or bleeding is a possibility. And even if are just giving them a completely inert supplement, to me that's like doing financial harm if you know it truly is not indicated and you're convincing them it is. So anyway, I. Anyway. Setting aside the idea of harm I just wanna point out that as doctors and especially as PCPs, a big part of our job is convincing people to do stuff that they don't wanna do, like their colonoscopies and their mammograms and their vaccines, and also then talking them out of things that they do want, like antibiotics for their viral infection or steroids or. The MRI for their back pain that started yesterday and has no red flags, right? So a good PCP, is going to be able to communicate the reason and, to follow those evidence-based guidelines and still have the patient be satisfied and. And luckily that's much easier to do in DPC'cause you have more time with people and don't have to rush them through that and can really make them feel empowered and involved in decision and understand why you're doing that. But when you start going down this slippery slope of doing what, just doing something because yes, the patient just really wants that. And that's what the people want and it's not harming them. So let's just do it. You are on a slippery slope to quack town, let me tell you because. Medicine is very unique in that there's this information asymmetry. You have this knowledge to know whether something is truly necessary or the right decision or indicated or not. The patient does not have that knowledge they do not have the ability to decide whether you made a good decision for them until probably way after or if they got a second opinion, right? So they need to trust you to make decisions that are right for them. And in traditional practice when you're billing insurance and everything is going through that filter, there's guardrails on what you can do. You can't go ordering MRIs on every single person with back pain because insurance is not gonna cover that. And they're gonna say, excuse me, please wait six weeks, and do pt, or prove to us that they have a red flag or whatever it is. And of course we all know that, insurance goes way beyond that and makes us jump through hoops for completely appropriate care. When you're in DPC, there's no guardrail at all. You could be telling the patient to do whatever you want, and there's really no other party that is watching and telling them, Hey, actually, that doesn't make sense. That's not indicated. That is not an appropriate medical decision. That is not standard of care. No one is there to tell them that. And so there is a lot of inherent trust that must be. Built and maintained in direct care. And I think that the doctors who go into direct care and then slip down this slippery slope to doing non-evidence based treatments because it increases patient satisfaction, or patients just want it, or they think it's, they think that has a lot of value, but obviously we know it doesn't. They are eroding. That trust long term, not only among doctors, but also among patients. So even if you're doing evidence-based medicine like 90% of the time and you're just doing a little bit of nonsense on the side,'cause you're like, oh, it'll get people in the door and this is what people want and this is what they're Googling. The patients may not initially notice or have a big problem with that. Your colleagues are definitely gonna notice. They're gonna assume that you're doing mostly nonsense. They're gonna assume that's what DPC is about. And I just feel like over time, if people keep moving in that direction, we will continue to be lumped in with basically like med spas and these shady weight loss clinics on the corner. And I just, I feel so strongly that the mission of DPC and the. Especially the doctors that I've worked with and I've mentored we're so far from that. And I, it just breaks my heart for people to assume that's what we do. I, my vision is eventually, I don't certainly wanna make the whole world DPC or anything like that, but I, my vision is just that. Eventually, all graduates going into primary care are aware of DPC. They understand the model and that it feels, for those of them that, it's a good, fit for, it feels like a legitimate, viable, respectable, reasonable option to practice primary care and, again, realistically, there's only gonna be a small percentage that really can do this or want to do this because it involves, a lot of other skills and, financial risk and so many different things. But I think that long term, having the majority of DPC doctors practicing EBM is what's going to help. Direct primary care and bake it into the mainstream. And remain in the mainstream. So now a question I see a lot of people ask in non DPC groups when they hear about DPC is can you do that without any gimmicks? Can you do that if you don't have, a niche like lifestyle medicine or women's health or, can you just do straight up evidence-based internal medicine or evidence-based family medicine? And have a successful practice. And I think there's an assumption amongst a lot of people that you've gotta give people something extra, otherwise they're not gonna see a reason to pay you beyond what they might pay for their insurance premium if they have insurance. The answer to that question is. Yes, you can a hundred percent be successful doing only EVM. I only do evidence-based internal medicine. I have no other gimmicks. I don't do aesthetics. There's no B12 shots for quote energy. I don't do pellets. I'm not doing anything else. Just straight primary care. And every single person that I've interviewed for this podcast is also just doing evidence-based primary care. In fact, I probably will not. Highlight or showcase anyone on this podcast who is going outside the realm of evidence-based primary care, because it's really important to me that we as a community show people that we are not some strange alternative to standard care that we are just trying to practice. What we view as good evidence-based primary care in a model that allows us to do that better than the insurance-based model does. So the answer to the question is, yes, you can be successful. Now the question is how? Why? Why would patients pay extra if you're not giving them anything extra? If you're not adding bells and whistles if you're not making the physical and executive physical? So I wanna remind you that the true value in DPC comes from. The transparency in pricing, they have a very clear idea of how much your services are going to cost. It's very predictable. There's no surprise bills. It's upfront your availability and accessibility. When your panel is one 10th the size of a typical panel, you can see people the same day, the next day. They don't have to wait for an appointment. They can contact you directly. That level of availability and accessibility is unparalleled. You don't get that in you. It's very hard to get that in any traditional practice. And then you know, the quality of their experience. You don't have to have this rushed 15 minute visit. You can spend as much time with your patients as you want, as your practice allows. For most of us, that's going to be, at least 30 minutes for appointments. I spend an hour and a half on the first appointment, yeah. I'm not offering them, any crazy, giant micronutrient panel I'm doing standard labs, like very standard labs. But just the experience of being able to talk through their entire history to allow them to explain all of their symptoms and describe them to me and to be listening and to just be present with them and not be rushing to get to your next patient or, just staring at your computer and typing the entire time. That is where a lot of the value is. And even without doing all of this other stuff, you can give patients. Value and experience that is way above and beyond what they're gonna get in traditional practice. And there is no need to add gimmicks or snake oil or, no, there's no need for little money grabs along the way. What I find. The types of people that typically go down that road. It's often, I think there's one type of doctor that, that genuinely in their heart of hearts believes that some of these things are, that ivermectin really is the cure for everything. And that vitamin C infusions like really do make everyone's cold better. And some doctors genuinely believe in those interventions. I can't say much about that. That's fine. They're entitled to believe what they believe and to use their license however they wanna use it. Then I think there's some doctors who know that some of those things are kind of baloney, but they're like people just, people want it. People just feel better when they get, some IB vitamins or people just feel better when they get a B12 shot or, and they're totally aware but they think oh, but it's not really harming them. That's the category that I really just wanna convince to not. Just don't do it. Just please don't do it. And then I think the last category, which is the saddest category, is when people can't figure out how to be successful doing evidence-based medicine. So they have to reach for these other things and their, their business owners, they've gotta keep the lights on, maybe they gotta pay their staff, they've gotta bring home money for their family. And, they feel as though, or they cannot make it work any other way. And so they're adding these other services when I'm talking to patients, sometimes I'm like I try to emphasize to them, sometimes more is not better. And when people are throwing the kitchen sink at you, ordering every lab, telling you to take every supplement, like all of these things, sometimes the more things they're testing and recommending for you, the less they're actually thinking about your case and. Thinking about your situation critically and applying knowledge and experience that they have, and I feel like I see that all the time with I don't know how to phrase it. Lesser trained professionals or providers of care that will basically just throw the kitchen sink, get every single patient, which, in the cash based world can be very lucrative, but is not necessarily good medicine at all. So anyway, those are the three categories. So it's really, the people who genuinely believe these things that they're doing are the right medical decisions. I'm never gonna talk those people out of it. They're gonna believe what they wanna believe, but I want to convince people who are just kinda oh, maybe I'll just do it and that's so bad. Please don't do it. And then for the people who are like, I'm having trouble being successful doing just the evidence-based medicine, I don't feel like that's attracting patients. I feel like I need to do these extra things. I hope that, that. The tools and, information that I'm providing you will help you be successful doing just high quality medicine so that you don't feel that you have to go down that path. Okay, so lastly I just wanted to talk a little tiny bit about some of the ways I talk about evidence-based medicine to my patients. So just as doctors have, their own assumptions about what you might be doing in a cash-based practice, sometimes patients are also going to have those assumptions. A lot of the patients who are open to doing a cash-based practice have done other cash-based wellness. Things. And so they've been to functional medicine doctors, they've been to med spas, they've been to quote wellness centers. And so they have now been convinced sometimes that, yeah, it's just totally normal for your doctor to just give you a B12 shot every time you come in. It's totally normal to just get shot up with steroids. Every time you have a cold, it's totally normal to, start antibiotics to nip, quote, nip something in the bud, and they might have these assumptions coming in, and there may be a mismatch because you are trying to provide evidence-based medicine and they're they've become accustomed to, or they're expecting something different. So some of the phrasing I use when I talk about, my style of practice is that, I tell people anytime I ask you to do anything, whether that's taking a prescription or a supplement, or removing from something from your diet, I consider that a big deal. I will see a lot of patients that have been to an alternative medicine provider who put them on 10 supplements and told them to take gluten and dairy out of their diet, maybe even sugar. That's like such a common, I feel like everyone walks in and regardless of their complaint, that will be the solution. And they often go there because they're afraid of taking a pharmaceutical or, going the route that you know, that a conventional doctor has recommended for them. But to me. Even removing things from your diet or taking over the counter supplements, all of those things are still a big deal. And so I, always try to remember this is a human being with a whole life to tell them like, oh, just stop eating gluten is not a benign intervention. And so I take all of those decisions very seriously and I believe that. I should have the highest level of evidence, like there should be a really solid justification for any of those decisions I'm making, and that is why I don't. Willy-nilly just recommend supplements that don't have good data. I, don't jump to giving antibiotics when I don't think they're indicated. I won't, give an MRI order just because, oh, it's no radiation and we just wanna see what's going on. It's no, is there an indication to actually do this test or this intervention? And I think that, that resonates with people. And you sometimes I'll point out, this other provider may be comfortable with a slightly lower level of evidence, and maybe that's, in line with their clinical experience and their style of practice and they feel comfortable making that decision with a little bit less data. I do not, and sometimes if it's something that, there's clear. The Menopause Society has guidelines around this thing. I will share those guidelines with them and say, look, the experts in this field who are much smarter than me, and probably smarter than this person who's telling you to do this other thing, have clearly stated that this is not the safest, option for treatment of your menopause symptoms. I am not going to presume that I am smarter than the, country's leading experts in menopause. And so this is not, what I do in my practice. And I think that does, I think that does resonate with people and this is something that they can understand and they can appreciate that. Look, the root of this is that I take the decisions I make about your health. Really seriously. And I wanna hold them to the highest level of scientific evidence, and rigor before I tell you to do that thing. And then when it comes to specific non-evidence based interventions that people are wanting, and this is very sad, science literacy is very low generally. And. Oftentimes it is just sharing anecdotes from your clinical experience that is the most effective in explaining to somebody why you will not do a thing. For example, I saw a patient back in medical school who actually ended up with liver failure related to taking red yeast rice extract as an alternative to statins for lowering his cholesterol. So I use that example when people ask me about that. I have a patient in my current practice who did like a mobile IV hydration service. Like he had come back from a trip to Mexico and was a little hungover and dehydrated and thought, oh, I'll get an iv. And he ended up in the hospital with sepsis and he saw multiple ID doctors and they were like. Is there something else going on here? And ultimately they were like, no, this was probably, an infection related to that, those IV fluids. And I tell people that story. I have had patients who have had terrible things happen after pellets, hair loss. Un unwanted hair growth, acne changes in their voice. So I share that. I unfortunately have a doctor who works in my area who a lot of my patients have seen in the past who seems to have this regimen for viral UR MRIs where she would give every single person a shot of steroids, a B12 shot and antibiotic prescriptions. So I have a handful of people that basically thought for years that was the appropriate treatment for like a. Cold and they, in the beginning all of them were disappointed when I was just like, no, that you're not getting any of those things. You're gonna have to use OTC meds and give this time and rest and hydration and see how it goes. And one of them actually ended up having some weird adrenal dysfunction. Like it was very, something obscure that Endo found. And, the only explanation they could think of for it was that she had been getting all these. Steroid shots when her, she got a ton of them the year her kids entered daycare. It, we know as doctors that anecdotes are anecdotes and they are not, the highest quality of evidence on which to be basing any of your decisions, but they're very compelling for people to know that, yes, I've seen this with my own eyes. This happens to people. And it's because I care about you and I care about your gut flora and your vaginal health and, your long-term ability to fight infections and, decreasing antibiotic resistance in our community. I am not gonna prescribe you this antibiotic for your, so anyway I think do not underestimate the power of anecdotes when you're trying to dissuade someone from some unnecessary intervention and remind them that financial harm is harm. A$2,000 whole body MRI, yeah, there's no radiation. There can be incidental findings there, it can give you a false sense of security if you're not under the care of a doctor. There's, the chance that, you're gonna chase an incidental loma or suddenly, pin your symptoms on something that is just an incidental finding. So many problems with it, but even if you don't fall down any of those, wormholes it's just, it's$2,000 that, you may not have needed to spend. And, financial harm is harm. Those are my thoughts on evidence-based medicine. What are your thoughts on evidence-based medicine? I welcome the angry emails because I think, what makes us smarter is allowing people to challenge our belief and exposing ourselves to opposing views. And so I'm open to hearing what your thoughts and criticisms are on what I had to say. So that brings us to the end of the show. Sorry, this episode was a little bit long. I announced in my last episode, but I'll remind you again that I have scheduled my next webinar for May 19th, which is a Monday at 8:00 PM Central Time via Zoom. I will include the registration link for that in the show notes. And I will also be sending out reminders through my newsletter, which is the Micropractice memo. So if you're not signed up for that, highly recommend, I promise I do not spam you. In fact. Sometimes I go MIA for six weeks, so it's not like you're gonna be getting a ton of extra stuff in your inbox. I try to make the newsletters very high yield. So if you're not already signed up for that, highly recommend doing so. Mark your calendars for that date on the 19th. The topic this time is going to be. Planting the seeds for Micropractice and setting yourself up for success. So honestly, a lot of the stuff I'm going to cover is going to be helpful even for people who ultimately do not start a micropractice or who maybe start some other kind of side gig, or basically for anybody who wants to build their professional brand out a little bit. And in my next episode I'll maybe share a few more some peeks about what I'm gonna cover in that. But stay tuned because I'm very excited about it. It's gonna be quite different from my previous webinar, so I hope you'll be able to join. Lastly, if you wanna connect with me, you have feedback, you wanna send me a mean email, you can send it to sonia@micropracticemama.com or dm me on Instagram. My handle is at Sonia Singh, S-O-N-I-A-S-I-N-G-H-M-S gm. I love hearing from you, so hopefully I will get a few Nice message to balance out the.