Physicians are punished for missing the rare diagnosis

In the article, Why do doctors use treatments that do not work?, several interesting points were made. It is making a case that we need to continually rely on the evidence, and less on empiricism. This is why it is so frustrating when I hear stories where EBM is tossed around like a “dirty word” and when physicians are making treatment decisions that are evidence-bereft.

. . . most drugs work in only 30% or 50% of people. Because patients so often get better or worse on their own, no matter what we do, clinical experience is a poor judge of what does and does not work. Hence the need for adequately powered randomised controlled trials.

. . . Even when empiricism is satisfied we can be misled by looking at the wrong outcome. Fluoride increases bone density. But it also increases the fracture rate. Flecainide for the treatment of supraventricular tachycardia makes the electrocardiogram look normal, but only after clinical trials (that some thought unethical) did it emerge that it increases mortality.

. . . Much of the clinical examination and diagnostic testing is more of a ritual than diagnostically useful. We continue to order routine blood tests before surgery without controlled trials to show benefit, and several case series that show that these tests rarely change outcomes or even management.

So, despite the examples above, why do physicians continue ignore the evidence? The following sums it up:

. . . Perhaps it is societal opinion (for which one ear of the medical profession is always pricked) that errors of omission are more reprehensible than errors of commission that is at fault. Is missing a rare diagnosis so much worse than harm from over-testing?

Let me address that last question – in our society, the answer is yes. Physicians are punished for missing the rare diagnosis, and never for over-testing. And until this changes, empiricism will trump the evidence more often than not.

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