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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  • http://www.facebook.com/people/Becky-Murphy/100000490494152 Becky Murphy

    The use of neuroleptic and other psychotropic drugs in Standard Practice without Informed Consent.  The pseudo-science of bio-psychiatry has done the field of Medicine and humanity the worst kind of disservice.  A claim based on belief alone that psychiatric diagnoses are “diseases” or “neurobiological” conditions—this is a Hypothesis–not a fact based on any definitive scientific evidence–yet it is a claim that is used to justify teratogenic chemicals being prescribed to millions of people around the globe.  These drugs are in widespread use—based on Practice Parameters and Treatment Protocols which ignore the science and are developed instead by consensus in a quasi-democratic process by psychiatrists.   The fact is, some of these drugs gained FDA approval based on utterly flawed, biased or unethical clinical trials which were inaccurately reported.  Not enough medical professionals are speaking out about what is in all reality, fraud and corruption-based Medicine, not Science-Based Medicine.   

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Evidence based medicine, comparative effectiveness research, outcomes based reimbursement, value based purchasing, patient centered care, consumer directed health care,…….
    All these terms are are part of a carefully crafted message for the masses, doctors included, and nobody ever stops to question their meaning anymore, and some are conflicting by definition, but all have a very positive upbeat sound, perhaps similar to the usage of “enhanced interrogation techniques” to describe the indescribable.

  • Anonymous

    The goal of evidence-based medicine is not subversive, as The Angry Orthopod suggests. The goal of EBM is overt, to “mechanize” those parts of medicine that can, and should, be automatic.

    Many routine medical decision don’t require med school – they have been defined in “rules based” algorithms and clinical pathways that prompt low-cost, low-risk solutions before expensive, invasive alternatives.

    - NO anti-biotics for viral conditions
    - Low-cost heart medicine instead of expensive brand names
    - Physical therapy for most degenerative spinal conditions before (or in place of) surgery
    - Behavioral treatments over routine medication for psychiatric disorders, as suggested by Becky Murphy.

    Even orthopedic surgery can be mechanized. As suggested by Clayton Christensen in The Innovator’s Prescription, the production line in high-volume orthopedic clinics can, and should be, modeled along the lines of the Toyota “lean” manufacturing process where skilled craftspeople assemble high-quality finished goods (happy patients) at a relatively low cost.

    Right now, the best, high-volume orthopedic clinics use these techniques to produce excellent outcomes. Costs, however, are stuck in the Medicare Resource Based Relative Value Scale, which over-values many procedures.

    The Angry Orthopod is right – medicine is changing from a craft that is defined by the experience and the license of the person giving the care.

    But, it’s not just EBM that is causing this change. Consumers and policymakers want safer, more convenient care. Payers and society want lower costs. EBM is a tool and a rationale to justify this change.

    Tim Richardson, PT

  • Anonymous

    I think of this as “kiosk medicine” (KM). I coined this phrase for my own convenience to tag medical visits that to me were indistinguishable from  entering an imaginary kiosk, being evaluated against pre determined criteria by a mechanical practitioner (robot) and sent home with a diagnosis and prescription determined by an algorithm. Some human practitioners have already been co-opted by this practice model. I take it EBM is a precursor for the kiosk.

  • Brian Curry

    What a load of post-modernist tripe. If you’re going to torture the very definition of EBM in order to fit your narrative of those evil, microfascist EBMers coming to take your clinical autonomy away, you might as well do the honorable thing and say so. In fact, I can find no mention in your post of what EBM actually is, save for a link to another kevinmd article by a similarly paranoid writer, who similarly seems to feel no obligation to define the term before pulling hair and gnashing teeth about it.

    The problem with both posts is that they conflate EBM with cookbook medicine. The problem is that they’re not the same thing, and so both posts fail miserably as a result, since the very foundation on which they’re built is nothing more than vapor and tin foil. This may be due to ignorance, so I’ll happily provide you with a citation you may wish to consult as a starting point: http://www.bmj.com/content/312/7023/71.full. You’re welcome.

  • http://twitter.com/JBizzle000 Jameson Bell

    The irony of this article is that orthopedics seems to be – in my experience – one of the fields most in need of EBM. Ortho. is one of the fields in which various surgeons seem to work in variously differing ways, with little concrete evidence to back up their practices. For example, despite many studies showing that arthroscopic menisectomy is of questionable benefit to patients who present without locking or obvious mechanical difficulties, it is still a widely practiced treatment that arguably does more harm than good in the long run. Instead of insisting on conservative management with whiny patients, orthopods are quick to put them under the knife, often leading to long-term arthritic pain.

    I truly hope that EBM DOES make more inroads into orthopedics and various other fields (psychiatry, as mentioned previously by another commenter). Only then will we see better patient care and decreased medical costs.

  • http://pulse.yahoo.com/_HSREMJ3JXCNVUF7MZVSLL4SM7U James Vell

    The irony of this article is that orthopedics seems to be – in my experience – one of the fields most in need of EBM. Ortho. is one of the fields in which various surgeons seem to work in variously differing ways, with little concrete evidence to back up their practices. For example, despite many studies showing that arthroscopic menisectomy is of questionable benefit to patients who present without locking or obvious mechanical difficulties, it is still a widely practiced treatment that arguably does more harm than good in the long run. Instead of insisting on conservative management with whiny patients, orthopods are quick to put them under the knife, often leading to long-term arthritic pain.

    I truly hope that EBM DOES make more inroads into orthopedics and various other fields (psychiatry, as mentioned previously by another commenter). Only then will we see better patient care and decreased medical costs.

  • Anonymous

    This article reeks of the paranoia that is common among physicians today. The author at once decrying EBM then proceeds to to make the case for the very type of medicine that he fears so much. Of course a competent qualified physician will use his experience together with all his study and research about new procedures being developed. He uses all sources available to him to determine the correct course of treatment for his individual patient and applies them in accordance with his experience. Of course… But what about the poor country doctor who has been practicing medicine “by the seat of his pants” all these years?? The author seems to say that this is somehow acceptable in a modern society. I say let those doctors stay in the country and let patients who want that kind of care move there too. I prefer to stay in the “city” where real medicine is being practiced.

  • heartsurgeryguide.net/

    i can not speak for orthopedics, but in the field of cardiology and cardiac surgery ADHERENCE to evidence-based medicine is a critical issue. maybe all practtioners read the literature and are smart and caring, but why after innumerable unassailable studies have shown the effectiveness of aspirin, beta-blockers, ace-inhibitors and statins in at risk individuals are a significant number of patients’ outcome compromised because they are not appropriately prescribed these drugs? much of medicine is cook book, despite the self aggrandising folly of many practitioners. evidence -bsed therapy should be the default position, this allows more efficient utilization of physician extenders and the “angry physicians” can concentrate on the vast minority of decisions that require indivualization. after 30 years of academic cardiac surgical practice in very tertiary referral institutions ( i wear this ego openly), i strongly disagree with the premise of this posting. best practices therapy/diagnostics gets best results at least cost, and at this time, that is most critical

  • Anonymous

    Well Dr. Agry Orthopod…Speaking as an “end recipient” (patient), I would much rather my doctor consider all the evidence that may or may not  be in cookbook format and then make the best decision for my personal situation.  How arrogant of you to think that you know more than scientists and researchers who can compile and grade the mountain of information that may be available on a particular therapy…from a non-biased perspective.  I think the docs that don’t think they need a cook-book need them the most.  Get with the program or get left behind!

  • Anonymous

    From MedicineNet: “Evidence-based medicine: The judicious use of the best current evidence in making decisions about the care of the individual patient. Evidence-based medicine (EBM) is mean to integrate clinical expertise with the best available research evidence and patient values.”  
    This is the second rant against EBM that I’ve seen recently – both referring to EBM as “cookbook” recipe medicine.  It’s not doctoring by numbers (see the ref from Brian Curry, below, for what it is and what it isn’t.)  The medic brings their clinical experience and the evidence which they judge is most applicable to their individual patient.  Patient input must also be taken into account.  EBM is as a result extremely individual-patient-centric.
    The other expression in vogue is “bench to bedside” – looking at how to get newly emerging best practices (be they drugs, procedures or protocols) to the patient as soon as is safely possible.  Misinterpreting EBM will delay this process, and as I’m (potential) patient rather than physician, I’d hate to see that happen.  I’ve had first hand experience of EBM correctly applied and it must not be rejected through lack of knowledge as to what it is.
    It is up to physicians to ensure that it is not deliberately misconstrued by head bottle-washers as a means of cost-cutting or anything else that does not put patient care as a priority.   

  • Brett Mello

    This is not about removing discretionary decision making from physicians
    or an effort by “non-academic dummies” to control them but rather a way to assist
    caregivers and facilitate effective, consistent outcomes.  There is no
    way a physician can possibly stay on top of the massive amount of
    changing information in healthcare delivery or best practices.  Evidence Based Medicine (EBM) puts all of this info at their fingertips to help guide, not control, your clinical work so that they
    can provide the best care possible.  EBM in no way removes the “latitude” to treat patients on an individual basis. You can still deviate from the
    recommendations if you feel it is necessary for the unique care of your
    patient. 

  • http://twitter.com/AustrianSchool_ Austrian School

    “That which can be asserted without evidence, can be dismissed without evidence.”

  • Anonymous

    I think evidence based practice should form the basis of clinical decisions, not BE the clinical decisions. In my opinion, EBP discourages practitioners (this is a problem in nursing too) from critical thinking and really looking at the patient. We’re creating practitioners who follow the protocol to the letter and take care of the monitor, not the patient.

  • Anonymous

    The problem with EBM is that it determines treatment based on the old bell-shaped curve.(This is going on in education, too). Which is all well and good for those who fall under the hump of the curve. And I know that in medical school, you are trained that when you hear hoofbeats, think horse, not zebra. But that means that we zebras are in a world of hurt. If you happen to be atypical in any way, EBM will NOT take care of you. Case in point: last year, I was very sick, and having an established diagnosis of diabetes, I got a lab test with a fasting blood glucose of 302, liver enzymes in the 100′s and an A1c of 10.7. Well, according to published tables, that A1c should translate to an average blood glucose of around 250 (I was actually running from 400 – 600, even while taking insulin), so the doctor was not terribly upset, and sent me home without doing anything. Well, 6 days later, I was in a coma, and only survived because friends came looking for me after I didn’t show up for a picnic. What the doc, an endo, had never paid attention to was the fact that my A1cs have NEVER correlated with my average blood glucose at all. I was diagnosed with separate fasting BGs of 138 and 131, BUT with an A1c of 4.8, which is well within the normal range.  I’m definitely a zebra, but I want health care as good as what the horses get!

  • Doug Capra

    This issue isn’t about the judicious use of evidence based medical practice — it’s not about trusting individual doctors. It’s about trusting the medical industrial complex — a combination of the huge corporate hospitals, the drug companies, the insurance companies. It’s about how they will use this information to dispense medical care. And, it’s about how this “evidence” is gathered and the competing interests in the gathering process. How much fraud is there in academic circles? How often do we read about this or that “evidence” for this or that treatment — then the next week another study comes out and says the opposite? How deep are the drug companies into these “studies” and this “evidence?” Most patients trust their individual doctors. I would suggest most don’t trust the huge economic interests running the medical industrial complex.

  • http://www.facebook.com/people/Robert-Weiss/1301131390 Robert Weiss

    Thank you Dr. Orthopod for expressing my feelings about the
    current situation in the U.S. concerning the treatment of lymphedema. Currently
    many insurers and CMS do not cover the treatment protocol called “complex
    decongestive therapy” which comprises manual lymph drainage, compression,
    exercise and skin care because there is little high-grade evidence which shows
    that it works. Never mind that it has been successfully practiced in Europe and
    Australia for over six decades. Academics performing systematic reviews
    of peer-reviewed journals typically limit their reviews to English-language
    publications which are less than ten years old, thereby discarding the evidence
    collected on hundreds of thousands of European patients treated over the last
    half-century. The evidence must fit some ideal theoretical quality profile or
    be discarded. The goal of some of these academic analyses seek to determine
    “the optimum protocol” for diagnosing or treating lymphedema, leading
    to provision and covering only one protocol of a multi-protocol treatment (e.g.
    only MLD but not compression). The physician is denied the option to chose the best
    combination of treatment modalities at a given time for a constantly changing medical
    presentation. 
    Consider if we had to treat all cancer patients with either surgery
    only, or radiotherapy only, or hormonal therapy only, or whatever other single
    modality determined from a search of recent American literature to be
    “optimal” for a majority of patients. And yet this is what was done in 2009 by CMS in commissioning a study of lymphedema diagnosis and treatment literature for a MEDCAC review. 

  • Joe Kosterich

    Virtually all “evidence” is statistically   based so nothing works for everyone. The practice of medicine remains an art based on science. The cookie cutter model reduces humans to being cookies.

  • Gray Somers

    The practice of medicine is based on an accumulated and emerging body of scientific evidence coupled with anecdotal experience. When applied rigorously, thoughtfully and consistently it enables the physician to provide the best standard of care individualized for each patient.
     
    The problem with Dr. Orthopod’s diatribe is that is paints EBM as a black or white phenomenon. It is no such thing. EBM still assumes that the physician will rely on his or her discretion to provide care. It does demand, however, that the physician consider available evidence-based practices in doing so. There is nothing “cookbook” about it.
     
    It is almost impossible for the individual physician to keep current with the staggering amount of information and data being accumulated in the medical literature. Being asked to consider best practices by another party or institution given the almost inevitable inability of the physician to stay on top of such data is neither “subversive” nor “cookie-cutter.” It is simply good, common sense.
     
    Not long ago the standard of care for low back pain was surgery. Needless to say this resulted in unnecessary morbidity and mortality and was wholly inefficacious in most cases. Despite evidence to the contrary this practice was continued until third parties i.e. the non-orthopedic community intervened. Being held accountable for utilizing “best practices” is not bad medicine. Being unwilling to do so is.

  • samson dy

    and who will monitor and paid for this process even if its at random pick up of cases will still be lots of money to administer. will most pcp go for cme meetings to educate to the most recent but expensive rx, procedures and drug? my opinion. SDR MD Inc

  • http://www.facebook.com/gojen.singh Gojen Singh

    VERY NICE ARTICLE

  • http://pulse.yahoo.com/_WWEC2BM6SYRIYQJQ2LOYFPRGCE Susan Fitzgerald

    I find this very amusing. This is exactly the logic MDs have used for years against the practice of medicine by licensed doctors of naturopathic and Oriental medicine.

    And, for the record, YES, MDs DO make things up. They prescribe medications for which there has been no testing. Why are infants getting GERD medications? Where’s the testing and literature on that? Why are toddlers being prescribed antidepressants – where’s the testing and literature on that?

    A colleague of mine was taking a GERD medication – refills approved by numerous doctors in two states – for SIX YEARS, when the small print says to take for no more than a few days or weeks. When she finally was near a complete breakdown from malnutrition, the doctor treating her for RA sent her to a naturopathic doctor to figure out what (else) was wrong. She was so low on B-12 that her cognitive function was impaired. It cost her a job, and her health. Where’s the “practice of medicine” there?

    Doctors are prescribing proven-dangerous sleep meds for months and years on end, contrary to FDA recommendations that it be taken no more than two weeks at a time. Where’s the “practice of medicine” there?

    My doctor insisted I get a bone density scan, though I had NO risk factors. Just happened to be a service she offered on site. I paid out of pocket for that because my insurance didn’t cover it because I had NO risk factors. Bones are fine, btw.

    EBM? I’m fine with that. If you want to deviate from the standards of care set by your own profession and specialty, just make the reason clear in the chart notes, and demonstrate that you’ve consulted with the patient on it. That should be sufficient to cya, as well as fulfill your sense of autonomy, for which, by the way, the rest of us are paying, in money and health.