Don’t ignore the evidence for the sake of argument

I regularly read a website called Medinnovation. It’s written by Dr. Richard Reece who tends to rant about healthcare in a refreshing way that you don’t often see online. He basically gives you his opinion with both barrels and it typically runs counter to what most people have to say. I like it.

This morning (broke my rule about Sunday morning reading, Doh!) I read his latest post, Medical Experts and the American People. This is one time when I think he got it wrong. In the article Dr. Reece basically chastises evidence based medicine (EBM). “I say “presumably” because many patients or doctors do not necessarily buy the experts’ advice [i.e. evidence based recommendations] or follow instructions.” Uh-oh.

He continues the rant by quoting from March 31 Wall Street Journal article “The Rise of Medical Expertocracy”

“For patients and experts alike, there is a subjective core to every medical decision. The truth is that, despite many advances, much of medicine still exists in a gray zone where there is not one right answer. No one can say with certainty who will benefit by taking a certain drug and who will not. Nor can we say with certainty what impact a medical condition will have on someone’s life or how they might experience a treatment’s side effects. The path to maintaining or regaining health is not the same for everyone; our preferences really do matter.”

Dr. Reece finishes by saying “I agree with these observations and conclusions. In the end, there is usually no single right answer to treating an individual, and patients, in conjunction with their doctors, have the right to choose what to do. Despite the rise of medical experts, armed with vast accumulations of data, there still exists no single answer to most medical problems.” 

A couple of comments about this. First and foremost I agree that patients, in conjunction with their physician, have the right to choose their course. But that doesn’t preclude the use of EBM. Second, EBM doesn’t mean letting someone else make a decision for you. It is designed to present you with the latest evidence to give you the information you need to make the best decision possible. Would you really want to do something that has been shown to be detrimental, or miss out on something just because you were too stubborn to look at EBM? If you said yes, it’s an injustice to your patient.

Sometimes there is a single best answer to a medical problem and that’s where EBM shines. I have to laugh when a physician screams that they don’t need EBM telling them what to do and that every single patient is different, only to turn around and write for the exact same medications for the same problems over and over again. How is that different? Did they treat every patient differently? I don’t know. If you use HCTZ for every patient you have with primary HTN, you haven’t exactly gone out of your way to individualize them now have you.

When I used to works nights as a pharmacist in the hospital I could tell you exactly what type of admissions I was going to see and what my technician and I would be doing based on which physicians were in the ED. Prior to starting my shift I’d wander down to the ED and see who was working. That gave me a mental head start for what my night was going to be like. I knew before I started work what medications I’d need on hand, what type of IV load I was going to have, whether or not I’d need to do a lot of vancomycin or gentamycin kinetics, and so on. Why? Because they treated every patient that walked in the door exactly the same way, that’s why. There was no “every patient is different approach”.

Would you want your physician deciding what TB meds to use on you if you had a newly diagnosed case of active TB instead of following the most recent guidelines? You’re a fool if you do. That’s a good way to develop a nice case of multi-drug resistant TB that could make your life miserable down the road.

Ever see a post-op CABG order set? Yeah, those are developed based on EBM and contain about 30 different medications. Any physician that says they’d rather write one of those by hand based on their own ‘opinion’ after consulting with their patient is a liar.

Would you want your physician to think about what to do with you if you were dragged into an ED with sepsis? Heck no. I’d want them start fluids and throw a host of antibiotics at me. Which antibiotics? I’m glad you asked. There are guidelines with laundry lists of recommended antibiotics. They’re based on worst case scenarios and the belief that you’d rather err on the side of overly aggressive than not aggressive enough. Do you know why? Because studies have shown that you need to start fluids and antibiotics ASAP or your chances of survival goes down. Crud, start them in the ambulance if you’ve got me back there. No need to wait for the physician to mull it over with me.

Any pharmacist in the audience know how to treat a 65 year old patient admitted to the hospital with community acquire pneumonia? Of course you do. There are some great guidelines out there put together by the IDSA or other well respected professional organization. And I will guarantee you that those are the exact same guidelines followed by thousands of physicians in the U.S. Does it make them any less of a physician because they peeked at the guidelines for treatment recommendations? Uh, no.

The bottom line is this, EBM is not designed to take your control away. It’s there to make you a better practitioner. Does every patient require the same approach? Probably not, but to believe that every patient is so different that each and every one of them requires a new, unique set of treatment options is preposterous.

During my career I’ve probably interacted with more than a hundred physicians; some good, some bad. With that said, the ones that are the hardest to work with and make things hardest on the pharmacists and nurses are the ones that believe their opinion outweighs the years of research and study done by those before them.

I want a physician that not only has an opinion and years of experience, but one that doesn’t ignore EBM because their ego won’t allow it. We should all have opinions about things, and we should all strive to change practice if we think something is better, but we should not ignore best practice simply for the sake of railing against the system.

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