Evidence based medicine removes a physician’s autonomy

Evidence based medicine.

Just think about it for a second. This means now we actually practice medicine based on bona fide evidence? What the hell have I been doing for the past 25 years? Making it all up? And who wrote those thousands of articles I’ve read? Dr. Seuss?

Evidence based medicine, or EBM, may be just another way to remove a physician’s autonomy. This trend has marched on for years, castrating us bit by bit. EBM is nothing more than the old process of peer-reviewed journal articles, but now there’s a classification systems that grades according to the article’s strengths or weaknesses. In other words, it’s to help the non-academic dummies tell the difference between crap and quality. In the U.S., a five-level scale is favored, while the U.K. prefers a four-stage system, and there are others.

My interest in this is truly for the end recipient: you, the patient. I think EBM at its core is a good thing, but its ultimate use must be questioned. The obvious objective for EBM is to arrive at the best care for the patient with a certain diagnosis. The subversive goal of EBM is to “mechanize” the whole medical delivery system and put the decision-making process on a prescribed pick list.

Forever, medical practitioners have enjoyed the latitude that allows them to treat patients on an individual basis. This is otherwise known as the “practice of medicine.” It employs experience, collegial interaction, and a reasonable knowledge of the appropriate literature to date.

This is where it gets weird. EBM is the current “buzz word” from med students to practicing physicians to researchers. Professionals speak of it like some new Holy Grail of medical research. In fact, it’s cool to be overheard uttering the words “evidence based medicine.”

Let’s just call it a sort of medical merchandizing. EBM is nothing different than all the scholarly literature that has preceded it for over 100 years repackaged as new and improved.

Of course the randomized, triple-blinded, placebo-controlled study is the research crown jewel, but those studies are far and few between, especially in our paranoid, liability-fearing world. Who decides the assignment of a level? Does a higher-level study render all lower ones irrelevant by default? Can’t I decide which articles are accurate and relevant, to me?

Now I’m certain my orthopaedic colleagues would never openly admit to what I am about to say even though they know it is true. Not to brag, but I knew what articles, chapters, and books were good and which were crap years ago. I still do. Experience and education leave me with the ability to accurately sort through this stuff and determine good from bad. I know just about everyone writing this stuff in my field, therefore I know who is and isn’t relevant. I’m not implying even one author is lying. It’s just that some write dribble rhetoric and some put out timely, novel, and useful work.

Most everyone thinks of this EBM stuff as all good. Doctors do, third party payers do, and let’s not forget Uncle Sam. Doctors, the ultimate holders of the key to patient care, are being lead to slaughter in years to come, and EBM is part of the puzzle. The health insurance companies love it as they can soon declare sweeping changes to save money in the name of “best practice” criteria. Finally, the government would like nothing better that to control the practice of medicine just like the military. Look how well our Veterans Administration system works.

While protocol can be good for medicine, policy is not.

If allowed, EBM will change medicine from a practice of individual-based, case-by-case care to cookie-cutter cookbook recipes. Maybe some docs need a cookbook but I don’t. The docs I respect don’t either.

“Angry Orthopod” is an orthopedic surgeon who blogs at his self-titled site, The Angry Orthopod.

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