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What is Your Threshold for Evidence to Treat?

Kanter, Steven L. MD

doi: 10.1097/ACM.0b013e3181a8bee3
From the Editor

In this issue of the journal, nine articles examine a broad spectrum of topics about osteopathic medicine, including the current state of education in osteopathic medical schools, the specialty choices of graduates of those schools, residency training issues for those with the Doctor of Osteopathy (DO) degree, and the clinical practice characteristics of osteopathic physicians.

In addition, there are two Point – Counterpoint sets of essays: one set examines whether or not physician education in the United States benefits from two separate programs that produce medical graduates (i.e., MD-degree-granting programs and DO-degree-granting programs), and the other explores whether or not core osteopathic principles are diluted for osteopathic graduates if they pursue training in residency programs accredited by the ACGME, in which the overwhelming majority of trainees are MDs.

As I examine the arguments for and against two separate educational pathways, and reflect on the similarities and differences among various philosophic approaches to medicine, I see a fundamental question that, I believe, lies at the center of these differences: How much evidence for a treatment’s effectiveness must be available before that treatment should be prescribed by a medical practitioner?

One’s answer to this question depends, in part, on how one’s philosophical disposition aligns with the traditions and values of education and training that lead to the MD degree, to the DO degree, to the practice of complementary and alternative medicine, or to other approaches to the relief of pain and suffering. Furthermore, one may reply differently to this question as a physician than as a patient.

For example, I know a physician with an MD degree who saw a patient with an inflammatory condition who wanted to take an herbal remedy to reduce the inflammation. The physician said to the patient, “I cannot recommend that treatment because there is not sufficient evidence to know if it reduces inflammation beyond a placebo effect. If you are going to take it, based on what you have read or based on someone else’s advice, let’s find out first if there are data about potential harmful effects or interactions with the other medications you take.” That is, the MD made recommendations based on a certain threshold for evidence to treat, and was uncomfortable prescribing or advocating the use of a remedy that did not rise above that threshold.

However, I also know that this same physician suffers with an inflammatory condition, which is well-controlled but not completely controlled by a standard therapeutic regimen. And I know that he has tried the herbal remedy that he was not willing to recommend to his patient. That is, the same individual required more evidence as an MD to prescribe a drug than as a patient to take it.

Another example of different responses to the “threshold for evidence to treat” question can be found in curricular design. While physicians with MD and DO degrees both value evidence-based medicine, a key difference between curricula that lead to the MD and DO degrees is the teaching of osteopathic manipulative medicine. In general, the philosophies that undergird the structure and function of MD-degree granting programs conclude that there is not sufficient evidence to recommend manipulative therapies. However, the philosophy of osteopathic medicine supports the inclusion of a course in manipulative medicine. This difference in approach to curricula is grounded, at least in part, in different responses to the question of how much evidence for a treatment’s effectiveness is required to justify prescribing it for patients, and thus teaching it to students.

Asking this fundamental question about threshold for evidence to treat not only helps reveal differences in various approaches to medicine and medical education, but also shows us common ground for useful dialogue and progress. In fact, it generates a number of important corollary questions, such as: Is the threshold for evidence to treat different for different conditions and situations? What should we teach students about thresholds for evidence? What threshold for evidence is required to make it ethical to prescribe a treatment? If the threshold for evidence to prescribe a treatment is too high, do we miss opportunities to relieve pain and suffering? If the threshold is too low, does it distract patients from getting proven treatments?

I propose that a productive way forward for adherents of all philosophies of medical practice and medical education would be to engage in discussion and research around the question of thresholds for evidence to treat. Perhaps this question, which lies at the very heart of our differences, is the very question that has the potential to bring us together. Let’s talk about it.

I thank Marc B. Hahn, DO, who served as the guest editor for this month’s collection of articles about U.S. osteopathic medicine and medical education. I am grateful for his outstanding efforts and for those of his colleagues, Peggy Smith-Barbaro, PhD, RN, and Dawn Kingdon, in working with the authors, Al Bradford, and other editors at the journal to develop and finalize the collection.

Ken Veit, DO, MBA, served as the coordinator for this month’s two Point–Counterpoint sets of essays on important controversies in physician education and training. I thank him for his outstanding efforts in working with the authors and Mary Beth DeVilbiss, one of the journal’s editors, to make this a cohesive and valuable contribution.

Steven L. Kanter, MD

© 2009 Association of American Medical Colleges