Evidence Based Medicine: Why it matters to be correct in applying it

[Mohawk1995]

I thought I would revisit this topic as it is a sore spot for me personally as a clinician that so few understand and practice it as it was originally intended. Great place to start is with the definition:

Evidence Based Medicine (EBM): "A systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values" Dr. David Sackett 1996

To put it more direct, it is the Clinician taking the best available research and filtering through it to identify useful points that, based on the clinician's experience and knowledge of the human body, can be applied to the individual patient in a way that is valuable to them. This then is the application of both Experimental Science (Randomized Clinical Trials for example) and Empirical Science (Current and Previous Observation in the real world).

What modern medicine has defined as EBM is only the application of Experimental Science noting that Empirical Science is biased. A deeper look at Experimental Science would reveal bias as well in the interpretation of these results and how they are used. By Physicians to over-simplify the disease process. By Healthcare Organizations to create Data they can then use to make decisions (typically financial) on. By Insurance and the Government to drive down spending. It can and should be useful to use the Experimental Science as a starting point and develop strategies based on it. It becomes problematic when you take these strategies and apply them to every disease and every person who comes through the door without the experience and knowledge of the provider. So "Clinical Prediction Rules", "Protocols" and "Population Health Strategies" are not all bad, but they fall short in the case of those patients whose presentation falls outside the parameters of the Experimental Research (Chronic Disease, Chronic Pain and ME/CFS as examples).

So in reality, for those cases that fall outside of the parameters of Experimental Research it is the Empirical Science and the collective knowledge of the provider(s) that becomes the driving force. It requires a keen knowledge of the body's systems and how they function, the best available knowledge of current theories on the cause and treatment of the disease, as well as the ability to correlate similar cases and treatment responses from other patients into the treatment program. This creates the support for "Off Label" use of medication and safe application of treatment protocols that insurances would likely determine are "Experimental".

Lastly it is important to note that the patient's values are included in the definition of EBM. What this means is that if the care provided does not add value (typically improvement or at least a better definition of what is wrong) then it is not EBM. It requires by definition that the patient should be a partner with the provider in the treatment process and should actively participate in choosing the form of treatment and engaging themselves in it.

So why talk about EBM in a ME/CFS forum? Because I believe it is the template for finding a cure or at least significant improvement in how we treat this disease (and many other chronic diseases). Also because the expertise and experience of many medical providers is being removed from the process of identifying and developing treatment for ME/CFS. AND because the patient's values are not being heard or considered in many cases.

 

[Wishful]

Even with diseases that are well-understood, there has to be the feedback from the patient and the doctor into the process. A lot of diseases share some symptoms, so the diagnosis can be wrong, and thus the treatment can be wrong, which requires the doctor to observe the effects and decide whether the treatment is working correctly. Also, even for the correct treatment, the patient might have some complicating factors unrelated to the disease, that causes a negative response to the treatment. So yes, "Here's your prescription, problem solved, don't come back." doesn't work.

the patient's values are not being heard or considered in many cases.

Too many of us are all too familiar with that problem: the doctor is too sure of himself and is convinced he is infallible. Maybe there's some way that doctors in training can be exposed to their own mistakes? What comes to mind is US fighter pilot training. Pilots were trained to do the maneuvers and hot to aim, but their death rate was highest on their first combat flight because they hadn't experienced their possible mistakes. Doing the correct-by-theory maneuver and finding the top gun instructor on your tail in perfect firing position would break the confidence that theory is everything. Surely there should be a way to apply that to doctor training.

Another idea: allow the patients a way to conveniently provide feedback. If it's directly to the doctor or the clinic, patients might be afraid of retribution for negative feedback. Also, doctors are busy enough and don't need more workload. Maybe some administrative office, where some experts can look for patterns (many patients complaining about the same problem) or those diseases where misdiagnosis is common (ME) and can direct the patient to a different doctor.

 

[phillybadboy]

the problem with cfs is the actual cause is known , people have theories as to why , so doctors are giving treatments when the cause isn't known ( harder to be effective this) . I've gone from doctor to doctor for the past twenty years , for the last past five years I've been doing my own thing , trying to find the answers myself , I think I've found it ( maybe not ).

 

[Mohawk1995]

Too many of us are all too familiar with that problem: the doctor is too sure of himself and is convinced he is infallible. Maybe there's some way that doctors in training can be exposed to their own mistakes?

I honestly think they are exposed to their own mistakes, but in a way that says you have to have an answer for the mistake. This probably reinforces the mindset that you can't make a mistake. I have seen younger physicians coming out of medical schools in the US with a more reasonable mindset and they are open to listening and learning. We can only hope for more of that!

Sometimes there just isn't a clear cut answer as is the case with many chronic diseases. I am thinking there is a real need for both increased training in a different approach to chronic diseases and also for a medical specialty and a clinic model that addresses chronic disease states. In particular those that we have such a difficult time addressing like ME/CFS, PTSD, Fibromyalgia/Chronic Pain and others.

 

[Davsey27]

I think evidence based medicine is a good approach as well as possibly including anecdotal based medicine as odd as this may sound

 

[Mohawk1995]

I think evidence based medicine is a good approach as well as possibly including anecdotal based medicine as odd as this may sound

Actually anecdotal based medicine is a key part of Empirical Science. Science based on observation of actual people or processes you hope to discover more about. It being a part of Empirical Science then makes it part of Evidence Based Medicine.

Anecdotal/Empirical Science has been largely ignored in the scientific quest for a "pure" answer that Experimental Science. However, it is impossible to find a 100% pure answer in Medicine as there are too many variables at play. There is also always some form of bias present no matter how well the experiment is managed. If nothing else, there is bias in the interpretation or conclusion of the results.