This past weekend the Boston Globe published an Op Ed by Sylvia Westphal.
[pullquote] IN THE pursuit of safe, effective, and cost-effective medicine, evidence is king. The medical profession believes that treatments should be studied in clinical trials, then compared against other regimens, before deciding what’s best for patients. Congress and the Obama administration have strongly endorsed this process by allocating money to evaluate the most effective treatments, in order to spare the public, and insurers, the burden of unnecessary procedures. [/pullquote]
This op-ed brings to attention the issues physicians and the public faces when considering just exactly what is implied (in reality) by the term “Evidence Based Medicine”.
We would all love to believe that the term EBM implies that a rigorously peer reviewed, conflict free article will help physicians and patients by guiding them on the appropriate treatment criterion and recommendations for a certain ailment or disease. Unfortunately, we are learning that the conflicts of interest that exist within the medical–industrial complex frequently lead to the publication of guidelines that are sometimes not only not in the patients best interest… but are potentially dangerous.
When a physician does not possess enough evidence to recommend a certain treatment vs another, they rely on their experience, teachings and knowledge base… so called eminence based medicine. For decades, this was the accepted standard of care. As we peel back the layers on the processes that produce these clinical pathways or treatment guidelines, we may in-fact discover that eminence based medicine wasn’t such a bad standard after all…. ???
Stay tuned as the Evidence-Based Medicine story roars on…
I’m looking forward to more discussion on this issue, Howard. In my opinion, the missing link with regard to the “ideal” of evidence based medicine and the (sorely lacking) state of the current evidence has to to with inadequacies in the data utilized to make decisions. Theoretically, if you had a database where you could plug in all of the pertinent information regarding a patient and could then obtain a complete breakdown of similar patients and what their response was to various treatments then the decsion as to which therapy would be (statistically) best would be easy.
There are two huge problems with this type of cookbook approach to evidence based medicine. #1: The current process of data extraction and analysis is not capable of providing historical results that are granular enough to account for every important factor in a given patient. However, given the way in which information flow has become digital it is not hard to imagine a time when the “googleization” of health data will allow us to have access to a much broader information with which to make individualized patient decsions. (At least I would hope so).
The #2 problem is a much larger one. This has to do with the fact that even if you were able to obtain data on a large group of *identical* patient’s and various treatments the answer you would get would still be only a statistical estimation of what works and what doesn’t work. Answers in clinical medicine are never empirically unambiguous. So if procedure A has a risk of 10 percent and procedure B has a risk of 50 percent, then procedure A is preferable; however for some patients procedure B would be preferable (notwithstanding its higher risk).
This second problem is not a matter of more data; but perhaps a problem of intuition and experience. So in the end even with perfect evidence, we still find ourselves leaning on the issue of “the art of medicine” to deal with difficult cases. Something I hope that patients will understand.
I am often struck by the complete reliance on EBM that many of us ascribe to, yet we forget that the basis of most diagnosis and therapy lacks truly rigorous evidence. Furthermore, each study has some flaw or limitations that prevents it from being completely applicable to our patients. No study can measure or account for every confounder or subgrouping. Perfect evidence will never exist.
In complex cases, it is frustrating that judgment (aka, the “art”) is often questioned by EBM pundits because of the dearth of data to support a particular hypothesis or treatment regimen, when no other diagnostic explanation or therapy has yet sufficed for the patient’s ailments.
I often remind people of one of my favorite pieces from the 2003 BMJ Christmas issue: “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials” (http://www.bmj.com/content/327/7429/1459.full), which recommended that such zealots get “organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.”
Fabulously evocative term: “eminence-based medicine”!
I don’t know if the proportion of doctors investing in diagnostic and/or treatment centers is on the rise or the decline, but I suspect it is on the rise, rendering eminence-based medicine [also] increasingly at risk of conflicts of interest.
Greater transparency regarding the financial interests and/or relationships of all professionals who are in a position of power or influence with respect to our health and welfare would be welcome.
THanks Joe… but can’t take credit for the term :-( Appreciate you stopping by.