Why Evidence-Based Medicine Won’t Work
“The unsettling reality,” the authors note, “is that much of medicine still exists in a gray zone, where there is no black or white answer about when to treat or how to treat.”
The books draws heavily on the approach known as shared medical decision-making, which has been promoted by researchers at Dartmouth College and others. This approach holds that doctor and patient together should review information about the risks and benefits of any given treatment and then customize care according to the patient’s values and preferences.
To illustrate, the authors use anecdotes from real patients like Dave Simon, an avid tennis player diagnosed with atrial fibrillation, an abnormal heart rhythm.
Too true. There are many, many gray zones in medicine. And when that happens, as it so frequently does, I want the doctor who’s been treating all my illnesses to help me make an informed decision. A third party just won’t do.
There is wide spread agreement on the need for consistent therapies that are backed by science. However, evidence-based medicine will not work the same on every single patient. There will always be patients who are outliers that respond differently.
Doctors get audited by CMS because they do not have “clean charts”. The problem is that not everything is medically necessary for every patient. Most of medicine is an art; however, there is some standardization in medicine, ergo outpatient clinics and UCCs.
There is no question that some patients would fall outside the bell curve in terms of the efficacy of standard protocols based upon evidence, but in my mind that argument is analogous to arguing we shouldn’t use medications because every patient will not respond favorably. If physicians allowed the reality that a patient might not respond favorably to a treatment drive their decision-making, then they wouldn’t be able to treat anybody. There is validity to the expression, “Common things are common.”
John, I typically agree with your opinions. In this case, however, I think it’s unwise–and costly–to go down the path of assuming each patient is the exception rather than the rule. @Aaron G, I respectfully disagree with your statement that most of medicine is an art. While medicine is both art and science, it’s definitely more science. Perhaps we disagree on what constitutes art.
I would agree the physician’s opinion should always overrule a standard in any case where he believes it contraindicated.
I think we just disagree on our usage of the word “art”. Don’t get me wrong, there are “best practices” but medicine is not a “machine” or widgets. You need to reason and rationalize. Some medicine does falls within this category.
I read medical studies and recommendations for kicks. Their recommendations range between black and white and grey.
Hey Aaron. I do appreciate your point of view. I mean that sincerely. As someone who’s worked in the healthcare industry for the better part of 20 years, I believe sometimes what patients perceive as the uniqueness of their symptoms is more the desire to be seen as an individual in a very personal situation. There’s nothing wrong with that, and that’s where bedside manner comes in, but there’s a big difference between one’s uniqueness as an individual and one’s uniqueness in clinical presentation. I think perhaps that’s where the line gets blurred.
You’re correct about the medical case studies, but keep in mind case studies are about the unique, not the commonplace. On top of that, doctors may be biased to reject the concept for no other reason than its capacity to reduce their own necessity. They are human after all! (doesn’t make them bad people)
I’m not saying my opinion as someone who works in healthcare is more valid. I’m simply saying my opinion as someone on the inside looking out is different than someone on the outside looking in. Generally speaking, people in the industry are far less personal about it than those outside of it.
Regards!
I’m convinced that the more data we have, the closer we can get to evidence-based medicine. Not all patients respond the same way to treatments, but it’s because we aren’t yet fully aware of how all of the variables come into play. In the same way that we adjust for sex and weight, I think we will one day also adjust for genetics and other influencing factors.
The reason that outliers exist is that we’re not taking into account all of the variables that go into the equation. The more variables we can identify and measure, the better we get at predicting patient responses to treatment.
I agree @Virginia, and I think it’s an important point when you say “the closer we can get”. The questions before is not whether evidence-based medicine is a perfect science. It is not, and neither is the traditional approach. The questions before us are whether the traditional, free-form approach to diagnosis is more effective than an evidence-based approach, which I don’t believe is the case, and whether evidence-based medicine is a more cost-effective application of the practice. Do we provide substantially more individualized care (without substantially better outcomes) to fewer individuals at higher cost, or do we use a less variable, protocol-based method that allows us to provide comparable, if not better, care to more individuals at lower cost.
Virginia is also right in that the more consistently we apply a specific treatment protocol to a specific clinical presentation, the better able we are to isolate the variations that make the standard ineffective and compensate for them. No one is saying there should be no art to the practice of medicine.