EVIDENCE BASED MEDICINE

Evidence Based Medicine.  This is a term you may have heard more and more in the last couple of years.  It has become a mantra among many doctors and most organizations dealing with traditional medical care.

What do they mean by “Evidence Based?”  Well, decades ago, there were far fewer clinical studies to guide physicians.  Their practices tended to be those they were taught by their elders, modified by the observations and experiences of the physician as he tried to put theses teachings into practice.  This is experience based rather than evidence based. Obviously, every physician has his own unique experiences to go on, resulting is a hodge-podge of practices.  Equally obviously, this wide array of practices cannot all be the “best.” 

So, over many decades we have seen an increasing number of clinical trials to try to answer the questions that previously were treated by experience and the conventional wisdom.  We have an increasing number of so-called experts telling us what to do, based on “the evidence.”   

At the outset, let me be clear.  I am a proponent of Evidence Based Medicine, but with one important caveat.  To use Evidence Based Medicine, you really need to look at and understand the evidence.  Most disease treatments and practices that are said to be evidence based really are backed by pretty convincing evidence.  Unfortunately, in other cases the evidence supporting a medication, practice or treatment is pretty flimsy.   Sorting all this out is not easy, and time constraints usually force physicians to simply “trust the experts.”  However, if a recommendation does not make sense or seems intuitively wrong, I think it is worth examining the evidence it is based on.

Adding to the difficulty is the fact that many of the so called “Best Practices” we see are actually being pushed on us, by which I mean both physicians and the people they treat, by large organizations that have a financial interest in the adaptation of the “Best Practice” they are pushing.

Take the pharmaceutical companies and medical device manufacturers.  They fund a huge portion of the clinical studies that are conducted and published. They have influence over the design of the study, and often whether it is published.  Any researcher who does not play ball with the companies is very unlikely to get more funding, and academic careers are fueled by research funding. 

Not surprisingly, almost all the clinical trials we see that have industry funding show an advantage for the product manufactured by the source of the money.  These reports constitute a fair portion of the “evidence” we are asked to base our practice on. 

Their answers are may well be correct, but they are always suspect.

Specialty societies also review studies and give recommendations that are based on “the evidence.”  So, why do we see one specialty society coming to one evidence-based answer, while a different specialty comes to a very different evidence-based answer?  And why is it that each society seems to have evidence that helps their members’ pocketbooks?  

And, the Government recommendation have their own problems.  The Government has a vested interest in keeping costs down, particularly for Medicare and Medicaid recipients.  Not surprisingly, for example, the government recommendations call for mammograms in far fewer women than do the recommendations from the American College of Radiology.  Yet, both claim to be evidence based.  

I like to use the analogy of the old Perry Mason trials on TV.  To solve the mystery, Perry always had to look at the evidence.  The evidence was not the answer.  It was the tool he used to piece together the solution to the mystery.  And when, for example, a witness was testifying to something that defied common sense, it was almost always wrong.  Medical mysteries are not very different. 

All this being said, let me just again make it clear:  I do believe in Evidence Based Medicine.  It gives us a way better chance of helping the people we treat than any alternative out there.  However, if the “evidence based” recommendation does to seem intuitively right or make sense, it pays to examine the evidence it was based on.

  Common-sense.