Confusing defensive with EBM

Medicine, like many other activities involving judgment and expertise has become defensive. If something goes awry or even not completely right, scapegoat hunting is fostered by visions of riches gained at little risk. In defense, the community develops standards and practices to use as a cudgel in defense against these attacks. The individual practitioner who follows these established mechanisms has a strong community behind him to help his defense.

The problem is that the standards and practices then become something to complain about. Like the 2000 Florida elections, there are people who are never satisfied, people who are always looking for some way to scratch their itch, people who just can’t accept reality.

Richard Dolinar MD provides an example of the backlash in Evidence-Based Medicine vs. Patients.

Is there, indeed, a best practice regarding the approach to elevated intraocular pressure? If so, how should the algorithm be constructed? Who should have the ultimate discretion in making that decision? Should it be the treating physician, with the best interest of the individual patient in mind? Or a third party with the best interest of the bottom line in mind?

Where Dolinar gives away the beans is in his choice of a straw man and in empty assertions such as the “interest of the bottom line.” The straw man is in choosing for his examples statistically based research with no definitive outcome. It is not honest to argue against evidence based decision making using examples without evidence. That straw man is accompanied by the litany of relativistic and soft armor:

Clinicians now fear medical malpractice suits if they do not follow EBM guidelines in treating patients. But as one resident recently asked me, which guidelines do you follow? Even guidelines about the same disease can vary substantially, depending upon which professional organization promulgated them.

EBM, by contrast, relies primarily on epidemiological data, which it uses in a way that preempts all other information collected by the treating physician. In fact, non-quantifiable information such as the patient’s values and the physician’s clinical experience are not even taken into account in EBM.

conflicting guidelines, which wizard to follow, non-quantifiable information, – let’s have a brainstorm session to invent more ways to rationalize our feelings! The falsehood here is that of presuming a binary distribution, a yes or no, EBM or not. The fact is that an MD is trained and licensed because there is judgment involved even with the best evidence to guide him. There is judgment to be made about which professional organization has the most to say in a particular case. There is a judgment to be made about the certainty of the evidence and its application in a particular case. There is a judgment to be made about the patient’s response and needs. The fact about EBM is that a physician should start with known evidence and understand its limits as a part of making diagnosis and deciding therapy.

Dolinar then ends in a basic contradiction:

The decisions whether and how to treat a disease ultimately lie with patients, who makes these decisions with their doctors’ help. It’s a value judgment, and there is no way to measure value. It is not quantifiable in inches, pounds, or miles per hour.

The ultimate discretion regarding how information from multiple sources (including EBM, prior clinical experience, and the patient’s unique circumstances, wishes, and desires) are integrated for treating individuals should be in the physician’s hands. Since he has the ultimate responsibility for the patient’s care, he should have the ultimate discretion.

The decision lies with the patients but is in the physician’s hands? No, the patient does not do his own diagnosis and decide his own treatment. What the patient does is to choose his physician and aid that physician in making decisions that the patient that can then choose whether or not to follow. The physician does not have an ultimate discretion because he is bound by the ethics of his profession and the constraints of his license. His discretion is limited by those constraints.

What Dolinar and others, such as those who advocate alternative medicine, do not do, where their lack of intellectual integrity is demonstrated, is that they do not offer a rational basis for using anything other than evidence as a basis for making decisions. They do not suggest any standard by which decisions can be based nor any standard by which outcomes can be measured. They misuse the precision and accuracy of measures that create evidence in order to misrepresent circumstances. They use the lack of absolute certainty in most aspects of medicine to toss out a proven methodology but do not offer anything to replace it other than whim and whimsy.

This gets into the reasons why certain professions require a license to practice in a jurisdiction. Society has learned that not having some controls in certain professions can be costly in many ways. Licensing may not be a complete solution but it is an effort towards a solution. Lawsuits are not a complete solution either, and there is much discussion about the abuse of the legal system and its impact on health care. Tossing out the baby with the bathwater as Dolinar seems to suggest, is probably not a good way towards finding solutions.

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