Meaning and Significance Of Evidence Based Medicine

Stanley Feld M.D.,FACP, MACE

I received the following from a reader after re-publishing Medical Care Must Not Be Converted To A Commodity.

"Hello Dr. Feld,

Can I ask a question regarding voluntary Physician compliance with evidenced based care. Your thoughts 

Who sets the guidelines (and changes them) and how do we get compliance when we know it takes a LONG time for new guidelines to gain adoption?

I believe a carrot and stick approach may be necessary with more carrot and less stick.  Your thoughts?

Thanks,

These are three great questions. They demand an answer.

1. Can I ask a question regarding voluntary Physician compliance with evidenced based care? 

This question is very difficult to answer with our present state of knowledge.

There is no Level 1 evidence based data available to the answer question.

Level 1 is evidenced based data is defined as;

Level I: Evidence obtained from at least one properly designed randomized controlled trial

2. Who sets the guidelines (and changes them) and how do we get compliance when we know it takes a LONG time for new guidelines to gain adoption?

I believe most practicing physicians try to comply with clinical guidelines written by their specialty organization. Most specialty organizations publish guidelines.

The guidelines are taught in courses physicians are required take to obtain Continuing Medical Education (CME) credits required for medical re-licensing. Guidelines by specialty groups differ slightly reflecting each specialty organizations clinical emphasis, clinical experience and clinical judgment in addition to the available evidence based medicine.

It would be nice to be able to determine if each physician in the country was up to date in every single area of medicine and surgery.

I would also be nice to have accurate measurable criteria to judge physicians’ practices.

How do you evaluate physicians’ judgment and clinical experience with a computer program? You can not.

This is the reason physicians object to cookbook medicine and the commodization of medicine and surgery. Physicians have been trained to use clinical judgment. Clinical guidelines and algorithms are a guide to help physicians reach the best conclusion they can reach.

The problem with evidence-based medicine is that does not define quality medical care. It defines the quality of studies that are rigid protocol studies that do not honor clinical observations, experience or  judgment.

I have made this clear with my observations about the deficiencies in the USPSTF’s studies and conclusions about subclinical hypothyroidism, the PSA value or the study of osteoporosis in men over 70 years old and breast cancer screening to mention a few.

In this era of decreased funding money for clinical studies that are random, double blind controlled research studies is rare.

Observational data studies and clinical judgment studies are considered weak and invalid.

Who suffers?

Patients suffer as the government takes over more of the healthcare payment system. Government is making consumers dependent on government’s healthcare decisions.  Government relies on the advice of the USPSTF to determine the value of treatments. Many of the USPSTF conclusions are invalid in my opinion.

Rather than going through the explanation of the shortcomings in Evidence Based Medicine (EBM), on which the conclusions of the USPSTF is based, I quote the literature and will let my readers judge for themselves.  

Evidence-based medicine (EBM) is a form of medicine that aims to optimize decision-making by emphasizing the use of evidence from well designed and conducted research.

Please note that clinical judgment and observational studies are not valued.

a. Although all medicine based on science has some degree of empirical support, EBM goes further, classifying evidence by its epistemologic strength and requiring that only the strongest types (coming from meta-analyses, systematic reviews, and randomized controlled trials) can yield strong recommendations; weaker types (such as from case-control studies) can yield only weak recommendations.

In my opinion meta-analyses is invalid statistical trick. It combines studies that do not have the same design. Each included study has different numbers of patient and different statistical power along with statistical significance. Combining different study designs does not increase statistical significance overall.

 b. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians.^[1]

EBM is one factor in improving medical care treatment. It should not be used exclusively in evaluating quality and paying for medical care.

Consumers of medical care are the ones that can evaluate the many factors that make up quality care. Unfortunately the government has no interest in the consumers of medical care. The focus is on decreasing the cost of care and not on improving the quality of care.

c. Use of the term rapidly expanded to include a previously described approach that emphasized the use of evidence in the design of guidelines and policies that apply to populations ("evidence-based practice policies").^[2]

It has subsequently spread to describe an approach to decision-making that is used at virtually every level of health care yielding the broader term evidence-based practice.^[3]

What is evidence-based practice?

Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that has been gaining ground following its formal introduction in 1992.

Its basic principles are that 1) all practical decisions should be made based upon research studies

2) That these research studies are to be selected and interpreted according to some specific norms characteristic for EBP.

Typically such norms disregard both theoretical and qualitative studies.

3) EBP considers quantitative studies according to a narrow set of criteria of what counts as evidence. If such a narrow set of methodological criteria are not applied, it is considered better just to speak instead of research-based practice.^[1]

Students of EBM, EBP, and EBBP are starting to recognize the limitations of Evidence Based Medicine (EBM).

The methodology used by the Obama administration should be change before both healthcare and medical care are completely destroyed.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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