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The limits of evidence based medicine… and what we can do about disability due to medically unexplained symptoms Copyright Dr. Rick Steele 2010
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The limitsof
evidence based medicine…
and what we can doabout disability due to
medically unexplained symptoms
Copyright Dr. Rick Steele 2010
Who’s talkin’?
Caught a few, lost more...
Leader of two failed clinics...
Richard Evan (Rick) Steele, MD, MPH, PDC, BCSPHM
Delta Omega Alpha inductee 2010
Chaser of windmills
The future???
Copyright Dr. Rick Steele 2010
What is evidence?
Generalizable
Valid
Reliable
Reproducible
A testable hypothesis
Copyright Dr. Rick Steele 2010
DBRCT
Double blind
Randomized
Controlled
Copyright Dr. Rick Steele 2010
What is reliable?
False positives and negatives
Test stability
Patient compliance
Generalizability
Problems
Copyright Dr. Rick Steele 2010
What is valid?Problems
Selection
Maturation
Interaction
Observer/observee problems
Copyright Dr. Rick Steele 2010
Is there a problem?
”Evidence” as an excuse to refuse to listen
Political ”evidence”
Administrative/bureaucratic ”evidence”
”Evidence” for the sake of evidence
Copyright Dr. Rick Steele 2010
Medically Unexplained SymptomsThe body as a state of mind
Stress and tension
The vicious cycle
Resilliency
Illness as a way of life
Disability
Copyright Dr. Rick Steele 2010
Diagnoses”Depression”
Pain syndromes
Multiple chemical sensitivity
Electromagnetic sensitivity
Chronic fatigue
Gulf war syndrome...
Copyright Dr. Rick Steele 2010
Numbers?
Enormous savings for society
Nobody knows – approx 3% of western populations
Extrapolated to US pop. approx. 10 million
Over half could be brought back to work
Copyright Dr. Rick Steele 2010
Cos
t of t
reat
men
t Work ability
0
100
0
100Intensive care
The treatment gap
Copyright Dr. Rick Steele 2010
Who are we?
Rick Steele, medical director
Public health specialist, MPHPostdoc certified. High level of competence in all medical andsurgical specialties as well aspsychiatry. Career 50% clinical,15% research, 15% teachingand 20% administrative
Copyright Dr. Rick Steele 2010
Birthe Moksha Jørgensen
Psykiatric nurse with years of experience with PTSDpatients. Expertise in adult training, psychotherapy, coaching and relaxation techniques. Therapy and supervision. Massage, craniosacral- and zone therapy.
Copyright Dr. Rick Steele 2010
Lene Kripa Henriksen
Body therapeut, psychotherapeut. Massage, acupuncture, craniosacral- and psychotherapy
Copyright Dr. Rick Steele 2010
Knud Buur
Job coach and much, much more (super social worker,among other things)
Copyright Dr. Rick Steele 2010
Torben Giehm Reese
Neuropsychologist, supervisor. Cognitive training, all round therapy
Copyright Dr. Rick Steele 2010
Julius Tschertok
Psychologist and then some. Hypnosis, cognitive therapy
Copyright Dr. Rick Steele 2010
So you just gather good people and go?
Copyright Dr. Rick Steele 2010
Klinikken Livet’s Pillars of Quality
PAT
IEN
T SA
TIS
FAC
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N
STA
FF S
ATIS
FAC
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CO
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IVE
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SS
GO
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AR
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PAY
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SAT
ISFA
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LIT
Y
Foratter: Rick Steelewww.klinikkenlivet.dkCopyright Dr. Rick Steele 2010
Go out to the patient
Save the patient from painful journeys
Gain deep trust quickly
Gain valuable information
Work locally
Copyright Dr. Rick Steele 2010
How to find the patients?Ask the social workers, their file cabinets are
full of them.
...don’t bother with the ones who refuse treatment
Copyright Dr. Rick Steele 2010
Target group
Any patient having been defined as beyond therapuetic reach by at least one relevant specialist
...don’t bother with the ones who refuse treatment
Copyright Dr. Rick Steele 2010
How to proceed?Preliminary exam
Expert study of the case to date includingany and all medical opinions, case material,and whatever other relevant material theremay be.
Ensure quick turnaround of referrals
Ensure quick booking of preliminary exam
Go out to the patient
Copyright Dr. Rick Steele 2010
Procedure (cont.)Preliminary exam
Contract with payer
Copyright Dr. Rick Steele 2010
Procedure (cont).Contract
Treatment strategy and elements
Interim and long term goals
Coordination of care
Cost estimate and payment stipulation
Copyright Dr. Rick Steele 2010
Procedure (cont.)Preliminary exam
Phase I
Contract
Copyright Dr. Rick Steele 2010
Procedure (cont.)Phase I
Intensive therapy
Minimal contact with payer
Relaxation, build up of cogntive tools,beginning of resiliciency development
Copyright Dr. Rick Steele 2010
Procedure (cont.)Prelinary exam
Phase I
Phase II
Contract
Copyright Dr. Rick Steele 2010
Procedure (cont.)Phase II
Bring in work related activities under continuedtherapy
Increasing contact with case worker
Increasing activity at work place
Decreasing therapy
Contact with employer (local)
Copyright Dr. Rick Steele 2010
Procedure (cont.)Prelinary exam
Phase I
Phase II
Contract
Phase III
Copyright Dr. Rick Steele 2010
Procedure (cont.)Phase III
At work, limited therapy
Support ad hoc and acute if necessary
Therapy fades out
Patient ”back to work”, mission accomplished
Copyright Dr. Rick Steele 2010
Procedure (cont).Phase III (alternative)
Back to social function
Therapy ad hoc and acute when necessary
Social function without support
Fading therapy
Copyright Dr. Rick Steele 2010
Is there another way?
If so, none have surfaced so far
Costly, but lack og treatment is immensely more so
Sucess rate? 60%
Copyright Dr. Rick Steele 2010
Discussion
Effective? YES!
Reproducible? Qualified yes
Generalizable? YES!
Expensive, yet highly lucrative for society
Evidence based? NO!
Copyright Dr. Rick Steele 2010
