Thursday, August 30, 2007
"Doctors do best when they treat their patients by the numbers"
McArdle on Groopman's How Doctors Think. I agree with her, and continue to advocate global, evidence-based measures (which also would help the medical malpractice/defensive medicine problem) to guide clinical decision making:Every profession resists being told that there is a standard way to do things, that a cookie cutter can cut better than their skilled hand. Journalists famously hate the "inverted U" style of writing a news story, even though it really does seem to work better than anything else; it's boring to write, and leaves no room for individual style. Teachers don't like "teaching to the test" or rigidly programmed phonics curricula, even though the latter produces measurably better results than all but the very best teachers. Unfortunately, for many of us, it may be time to welcome our new robot overlords.
Posted by Kevin |
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The problem with this is the same thing that happens with standard order sets and protocols. It becomes easier to just do the protocol without understanding why. So you may have no clue when the protocol isn't working or have no alternatives.
For diagnoses that are definitive and easy to arrive at, I agree that EBM is the best way to go.
However, EBM starts with a diagnosis and for many patients diagnostic uncertainty is their paramount problem, as well as failure to respond to the treatments for the disease they are diagnosed with. In these cases protocols can be disastrous.
If you assume a 15% diagnostic error rate, EBM becomes less attractive because you have to filter out the 15% of patients who are being treated for diagnosis they don't have.
EBM is also nearly impossible to apply to extremely rare conditions. How much EBM data is there for relapsing polychondritis for example?
However, EBM starts with a diagnosis and for many patients diagnostic uncertainty is their paramount problem, as well as failure to respond to the treatments for the disease they are diagnosed with. In these cases protocols can be disastrous.
If you assume a 15% diagnostic error rate, EBM becomes less attractive because you have to filter out the 15% of patients who are being treated for diagnosis they don't have.
EBM is also nearly impossible to apply to extremely rare conditions. How much EBM data is there for relapsing polychondritis for example?
This doesn't acknowledge that much of Internal Medicine is Psych, i.e. the "customers" are there for someone to talk to, more than to obtain a diagnosis. Or maybe they just want propecia or need to discuss diet options. None of this has anything to do with EBM, as well as much of medical practice. Patients often come without any medical illness. What robot is going to offer comfort to those who want to see a human being?
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