On evidence based medicine


Category : Medical Rants

Another Medscape roundtable:

Does “Evidence-Based Medicine” Diminish the Physician’s Role?

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Comments (6)

I think evidence -based medicine is essential and should be the norm for all physicians. Sometimes I’m appalled that it isn’t. It’s disturbing to me that people are still having routine physicals and exams when there is no benefit to it. It actually enhances the role of physicians when they are doing things that will make a difference.
All of this “routine” checking of asymptomatic people is a waste of everyone’s money and time, and it trivializes doctors and makes them pointless.
I think it also lulls people into false security when they have all these “check ups,” because while the doctor knows it is pointless, the patient often doesn’t. Pelvic exams are the perfect example of this. Women who have them actually think that they are “safe” by protecting themselves against ovarian or endometrial cancer. When it’s a truly a farce because the exam has no medical or preventative value in asymptomatic people.
Evidence based medicine has the potential to educate patients about their health, and dispel these potentially risky beliefs about how exams make people “safe.” Some people really obsess about periodic exams and even demand them because they think they are valuable. If they put that energy into a useful lifestyle change, maybe they really could prevent cancer, instead of rushing to the doctor for these pointless check-ups, thinking that they are doing “the right thing.”
Doctors can benefit, too, since useless exams/tests take up time that they could be spending on the necessary patient care. Healthcare could be streamlined and made much more effective if evidence-based would be the standard for everyone.
I think it is up to doctors to make it the norm. Patients are generally ignorant about what is really necessary, and tend to believe in whatever is traditional, whatever their parents told them, or whatever their friends say is a good idea. Doctors have to be the ones to educate them.

I am going to take the bold sin and say “evidence-based medicine is only as good as junior-high geometry”. What that is to say is that evidence-based medicine only goes as far as where we have evidence, links, and proofs.

Medicine should reach also for intuition and conjectures.

I can’t help but think about Poincare’s Conjecture (recently proven), and consider that medicine should be more like mathematics in its practice.

There are things that mathematicians know and use. Then, there are things that their intuition tells them, that they investigate further. Both of these are needed, foundations, and intuitions (and the intelligence and wisdom to know which is which). Both are required to treat the human.

Evidence based medicine, since the 1970’s, depended upon the randomized, controlled trial. It rests upon the assumption that evidence should be determined and applied as a basis for medical decision-making. Evidence is based upon quantities, similarities, populations, and averages, rather than qualities, idiosyncracies, individualization, and specifics.

Evidence-based medicine is a “trial and error” process of a clinical trials to see what might “appear” to be improving cancer survival. It is the mindset of rewarding academic achievement and publication over all else. There is this aurora that organizations, government agencies, scientists, researcher and even practitioners work together, sharing information for the benefit of patients.

Each group has its own priorities and its own agenda. Moreover, the image of cooperation between these different groups only gives the illusion that reform isn’t needed. The present system exists to serve academic achievement and publication, but not to serve the best interests of people.

The demise of the “discoverer” type with its not so well organized risk-taking, in favor of the “investigator” culture, well organized, exhaustive analysis of trivial hypotheses, is a perfect example of thirty years of the “trial and error” mind-set that has occupied cancer research. A dysfunctional culture that pushes tens of thousands of physicians and scientists toward the goal of finding the tiniest improvements in treatment rather than genuine breakthroughs, that rewards academic achievement and publication even though their proven activity has little to do with “curing” cancer.

While new regimens “appear” to be improving survival, when these same regimens are tested on a wider range of cancer patients, the results have been very disappointing. In other words, oncologists at a single institution may obtain a 40 – 50 percent response rate (not cure rate) in a tightly controlled study, when these same regimens are tested in a real-world setting, the response rates may be 17 – 27 percent.

Also, whatever clinical response that has resulted to the average number of patients in a randomized trial, is no indication of what will happen to an individual at any particular time. They are trying to identify the “best guess” treatment for the average patient. You cannot mate notoriously heterogeneous diseases into “one-size-fits-all” treatments.

Dr. Pennie Marchetti’s comments hit a chord. Unfortunately I have seen, or been subject too, the very behaviors she describes involving small market physicians. EBM ask the question: Does this treatment, in fact, do any good? Often the answer is no.

Myth and financial gain play a bigger role in medicine than most physicians will admit. EBM outlines the effectiveness of treatments and brings forth the concept of numbers needed to treat. Again, we find that often medicating entire populations, will bring about only marginal improvements in health.

EBM can be misused if it becomes a rigid template for treatment. Much like P4P, we need to be very aware of the appropriateness of those applications. Flexibility needs to be the key to all medicine, while still maintaining a strong tie to science.

Steve Lucas

Why does every one equate EBM with RCTs and guidelines? EBM is not about RCTs only; its about the best available evidence on a question. Sometimes its a meta-analysis of RCTs but many times its clinical experience. Let me repeat- best available evidence.

RCTs are not good designs for some outcomes (for example liver toxicity of a statin) because of sample size issues of an RCT. Thus observational studes become the best available evidence.

The concept of EBM currently is that it is the marriage of the best available evidence with pt values and clinical experience. It requires all 3 components.

EBM is but a tool to aid in the practice of medicine. It is a set of skills to appraise evidence and decide on its applicability to an individual patient. The decision on applicability requires understanding a patient’s values and expections and using your clinical expertise to determine if risks outweigh the benefits in that particular patient. Superimposed on this is the understanding of your practice environment- issues like formularies, availablilty of procedures, etc.

EBM is not about guidelines only. Its not about RCTs only. Its not an attempt to save money only. Yes it has been highjacked by some and equated to this but they have perverted what EBM is all about and given it a bad acronym

I will also challenge those to tell me do they want physicians to practice ignoring the evidence and to use their experience alone or physiological inferences only? Surely you dont want anti-arrhythmic drugs for your PVCs post MI! Shall I go on with more examples?

I believe evidence-based medicine has morphed into pharma-based medicine and HMO-based medicine. If you can eradicate the latter, you can renew credence in the former.

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