Combining the science and the art

5

Category : Medical Rants

Let me start with my background. Several years ago I was the President of the Society for Medical Decision Making. I have taught Basic Diagnostic Testing many times – and helped develop a course on that subject. I have written about Receiver Operating Charactertic Curve analysis and Likelihood Ratios. My CV includes cost-effectiveness analyses and decision analyses.

Given that background, I remain cautious about how we should view evidence based medicine. A recent blog entry at Health Care Renewal – The Post-Modernist View: Evidence-Based Medicine as Fascism? – discusses a critique of evidence based medicine. My post today will critique EBM in a slightly different way.

Physicians must learn the principles of evidence based medicine. We need to understand how to evaluate the literature, especially randomized controlled trials. We need to read critically.

However, we should not expect that EBM will solve all the problems in medicine. As I read EBM reviews, I often see biases. To do a review, the “expert” must evaluate the quality of the data. This evaluation is, unfortunately, a bit subjective. Often the “expert” has to make judgements using an implicit utility structure.

Let me give an example. We currently have two major guidelines on the care of adult pharyngitis – Principles of appropriate antibiotic use for acute pharyngitis in adults (ACP-ASIM) and Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis (IDSA) . Given the same problem and the same data, the two group propose different recommendations.

As one analyzes guidelines, we almost always find prejudices, because we cannot (and I would submit should not) quantitate every feature of medical care. The two above guidelines clearly have different vantage points. The ACP-ASIM guideline gives primacy to patient symptoms, while the IDSA worries most about “unnecessary antibiotics”. Each group uses the evidence to promote their world view.

The Cochrane Collaboration Review of pharyngitis looks somewhat different – Antibiotics for sore throat.

Available data suggests that antibiotics are of limited use for most people with sore throats

Sore throats are infections caused by bacteria or viruses, affecting mostly children and young adults. People usually recover quickly anyway (usually after three or four days), although some people have complications. The most serious possible complication is rheumatic fever, a disease affecting the heart and joints. Antibiotics can reduce bacterial infections, but communities build resistance to these drugs, and they can cause diarrhoea, rash and other adverse effects. The review of trials found that antibiotics shorten the illness by an average of about one day. They can reduce rheumatic fever in communities where this complication is common.

So which evidence based analysis should we use? I have picked this subject, because I have read the literature on sore throats for 25 years. These analyses frame an interesting philosophical debate in medicine – how do we balance patient short term suffering with theoretical public health concerns? But where does that leave one as a practicing physician?

The problem that I see with overzealous promotion of EBM is that is removes context from decision making. I had the good fortune to know one of the giants of Alabama Internal Medicine – John Burnum. Late in his career, he taught medicine at our Tuscaloosa campus. I would go there periodically to take morning report. We spent some time discussing medicine, and developed a catch phrase about patient presentations. One cannot discuss a patient’s case without acknowledging the context of that patient. I cannot think about the word context without remembering Dr. Burnum.

The point that I want to make (after a bit of rambling) is that EBM must be only one factor that we consider in our decision making. We must always consider the context of the patient.

What makes medicine so challenging is that patients vary significantly. Patients do not easily fit into simple definitions. We must temper evidence by the context of the patient.

Now we hear calls for more evidence on diagnostic testing – Diagnosis—the next frontier

The message I take from this is that while evidence based treatment is well on the way to being sorted out, evidence based diagnosis is still in the dark ages. This week’s journal suggests that things are beginning to change. In her editorial Sharon Straus states what should be a self evident truth: “When making a diagnosis in patients who are already ill we should be able to draw on evidence about the accuracy of diagnostic tests” (p 405). Yet just how far we have to go is shown by a study from Susan Mallett and colleagues of reporting and review methods used in systematic reviews of diagnostic tests for cancer (p 413). Lousy methodology means that “even these apparently evidence based studies are flawed,” comments Straus. Relief is at hand: those repositories of evidence based treatments—Clinical Evidence (published by the BMJ Publishing Group) and the Cochrane Library—are turning their attention to diagnosis.

Now I will object to two ideas here. First, I do not believe that we are well on the way to sorting out treatment. We have some good information, but patients are too complex to always fit into a simple framework. Second, I believe that we already have good information on many diagnostic tests. The problem with diagnostic tests is that they only give accurate information in the context of the patient. We must be able to estimate prior probabilities to evaluate any test. We must know which tests to order. We must think of a diagnosis or we will be unlikely to order the right test.

I applaud those who work to develop the field of evidence based medicine, but I caution them to not over sell the promise of EBM. EBM represents another tool in medicine. We should pay attention to the findings, and then apply them to our patients. But we must always apply these, and any other tools in the context of the patient. If we try to overemphasize the science without considering the art, then we are failing our patients.

viagra
free viagra
buy viagra online
generic viagra
how does viagra work
cheap viagra
buy viagra
buy viagra online inurl
viagra 6 free samples
viagra online
viagra for women
viagra side effects
female viagra
natural viagra
online viagra
cheapest viagra prices
herbal viagra
alternative to viagra
buy generic viagra
purchase viagra online
free viagra without prescription
viagra attorneys
free viagra samples before buying
buy generic viagra cheap
viagra uk
generic viagra online
try viagra for free
generic viagra from india
fda approves viagra
free viagra sample
what is better viagra or levitra
discount generic viagra online
viagra cialis levitra
viagra dosage
viagra cheap
viagra on line
best price for viagra
free sample pack of viagra
viagra generic
viagra without prescription
discount viagra
gay viagra
mail order viagra
viagra inurl
generic viagra online paypal
generic viagra overnight
generic viagra online pharmacy
generic viagra uk
buy cheap viagra online uk
suppliers of viagra
how long does viagra last
viagra sex
generic viagra soft tabs
generic viagra 100mg
buy viagra onli
generic viagra online without prescription
viagra energy drink
cheapest uk supplier viagra
viagra cialis
generic viagra safe
viagra professional
viagra sales
viagra free trial pack
viagra lawyers
over the counter viagra
best price for generic viagra
viagra jokes
buying viagra
viagra samples
viagra sample
cialis
generic cialis
cheapest cialis
buy cialis online
buying generic cialis
cialis for order
what are the side effects of cialis
buy generic cialis
what is the generic name for cialis
cheap cialis
cialis online
buy cialis
cialis side effects
how long does cialis last
cialis forum
cialis lawyer ohio
cialis attorneys
cialis attorney columbus
cialis injury lawyer ohio
cialis injury attorney ohio
cialis injury lawyer columbus
prices cialis
cialis lawyers
viagra cialis levitra
cialis lawyer columbus
online generic cialis
daily cialis
cialis injury attorney columbus
cialis attorney ohio
cialis cost
cialis professional
cialis super active
how does cialis work
what does cialis look like
cialis drug
viagra cialis
cialis to buy new zealand
cialis without prescription
free cialis
cialis soft tabs
discount cialis
cialis generic
generic cialis from india
cheap cialis sale online
cialis daily
cialis reviews
cialis generico
how can i take cialis
cheap cialis si
cialis vs viagra
levitra
generic levitra
levitra attorneys
what is better viagra or levitra
viagra cialis levitra
levitra side effects
buy levitra
levitra online
levitra dangers
how does levitra work
levitra lawyers
what is the difference between levitra and viagra
levitra versus viagra
which works better viagra or levitra
buy levitra and overnight shipping
levitra vs viagra
canidan pharmacies levitra
how long does levitra last
viagra cialis levitra
levitra acheter
comprare levitra
levitra ohne rezept
levitra 20mg
levitra senza ricetta
cheapest generic levitra
levitra compra
cheap levitra
levitra overnight
levitra generika
levitra kaufen

Comments (5)

I have been thinking a lot and blogging a little on the same issues you discuss here.We need to celebrate the utility of EMB and recognize its limitations.I fear that sometimes EBM has been oversold or at least over-bought by some.I have written more about its limitations as there is no shortage of its advocates some of whom are a little too enthusiastic and have missed or at least ignored your very important point of considering the evidence in the context of the patient.

I’ve found that the principles of EBM are useful in helping patients understand why a certain treatment or test is *not* indicated in a particular context.

EBM may be over sold but in veterinary medicine those who sell EBM have a difficult time even getting published.
I think The old “art and science of medicine” dichotomy probably applied very well
to pre-1930s medicine, but the science revolution that has occurred since
really makes the phrase redundant. What people refer to as “art” in medicine
is surely “judgment”. That is, tailoring science-based treatments to an
individual situation and guessing when to use placebos. Somewhere along the line medicine has to accept that
it is based on a materialist philosophy, and is wedded to cause and effect
(broadly defined). Everything else is not-science. The “healer” tradition in
medicine (with its roots in the shaman idea) should finally be buried.

art malernee dvm

Medical decisions, like most, require both judgment and data/analysis of data. EBM has a lot to offer I think provided it is in the context of the community being treated. Knowing what factors should be considered in deciding the risk level of an emergency room patient with heart pain is EBM. Actually evaluating those factors for a given patient is medical judgment.
One thing to bear in mind is that EBM lends itself to automation and automated support and this can be a powerful tool as discussed for instance by Mark Clare of Parkview Health http://www.edmblog.com/weblog/2006/05/live_from_inter_3.html or this more general discussion http://www.edmblog.com/weblog/2006/07/medical_errors_.html

I could debate EBM all day, but I certainly love that I stumbled across your blog. Keep it coming

Post a comment