How I learned to stop worrying and love practicing without EBM | Alert & Oriented – by Michel Accad – Sept 2016
My aim is to show you practical ways you can safely and effectively exercise clinical judgment without recourse to “evidence-based” knowledge, provided you follow simple but fundamental principles of clinical care: circumspection, parsimony, and due respect to patient autonomy.
What’s more, I will make my case against RCTs using examples that EBM apologists have precisely identified as paradigmatic of this “single greatest medical advance.”
Dr. Acacd then works through four population-wide cases when RCTs overturned “common knowledge” and EBM and changed medical practice.
But he also shows how a thoughtful application of “common sense” and “patient-centered care” would have led to the same care of patients.
I see the same issues with all the guidelines purporting to know what doses of opioids patients need.
The cases he details are:
- Hormone replacement therapy (Women’s Health Initiative trial)
- the famous COURAGE trial showing stents for stable coronary disease
- treatment of metastatic breast and lung cancer with bone marrow transplantation
- the CAST randomized trial on anti-arrhythmic medications after a heart attack
Mistaking the symptom for the cause
EBM is invariably promoted as a reliable alternative to the fallible clinical judgment of physicians, a fallibility that can mislead doctors on a grand scale.
To view EBM as cure for a systematic impairment in clinical judgment mistakes the symptom for the cause.
Besides, good clinical judgment can be taught and should be fostered.
If medical schools are failing in that regard, their preoccupation with obtaining research grants or generating clinical revenue may be distracting them from their primary mission. EBM and guideline medicine should not be substitutes for inadequate medical education.
So friends, let go of EBM. Be not afraid.
You were meant to use your intellectual abilities and your imagination, supplied by what you have learned from trusted sources and what you experience yourself, if you pay close attention to the patient.
You have pledged to serve individual patients.
That means that you must strive to be prudent and circumspect.
…at all times and, as much as possible, “particularize” the available information to the patient at hand, not “generalize” RCT findings to broad swaths of the population which is how EBM would lead you to practice.
So don’t let EBM turn your professional calling into a mindless application of rules. Instead, enjoy the freedom to do what you know is the right thing to do.
Most doctors want to do the right thing, but can’t when their management doesn’t allow it.
Corporate managers want their employees to mindlessly follow whatever standards they’ve set to create metrics (mostly meaningless without context, like MME prescribed) that can be used to further standardize (and cut costs) by sidelining doctors’ judgment and experience (too expensive).
This fiasco is the result of financial interests taking over healthcare: most doctors are no longer independent but must now report to their corporate bosses, who are more interested in and motivated by profits than patients.