The challenge of evidence-based medicine to the new physician

Evidence-based medicine (EBM) has been classically described as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”  At first look, this well-accepted approach to clinical medicine appears not only completely reasonable, but also somewhat obvious given the immense amount of research available for academic consumption.

EBM has been repeatedly preached as the gold standard of clinical care across all medical residencies, and various key studies related to patient cases are often proudly sermonized by both gray-haired attending physicians and kowtower trainees alike.   And they should: What better way to become educated in clinical medicine than by understanding where and how various current medical recommendations originated?

Despite EBM being an incredible advancement in the history of medical care and patient management, there remains many challenges that young clinicians must face when attempting to implement EBM into their respective practices.

1. Not all patients are alike. When advising workup and treatments to patients based on current clinical evidence, a new physician is often largely basing much of these recommendations on at least one high-quality study that demonstrated a clinical significant effect in a highly-regulated clinical situation.  This implies that in addition to hand-picking specific workup and/or treatments for studies in a controlled setting, participants are often similarly selected by meeting stringent clinical and demographical characteristics.

It is not uncommon for studies with highly selective inclusion and exclusion criteria to incorporate a study population that has completely different demographics to patients under the care of a typical practicing clinician, thus reducing any generalizability of its results to that physician’s clinic population.

A classic example is the ongoing issue the trend for many clinical study groups to exclude multi-morbid or elderly participants in their clinical trials.  How can a geriatrician practice EBM with clinical data and recommendations that are mostly created for a younger patient demographic?

2. Not all data is good data. Even if various studies are relevant to a patient’s specific condition, other various factors arise that hinders his or her practitioner from practicing EBM.  As mentioned in a previous article, not all data is good data — just because something is published in a journal does not mean it should be immediately incorporated into clinical practice.

Many research methodologies come with major biases: pharmaceutical companies often fund a large proportion of available research, and the publish or perish mentality of academic medicine may push investigators to use any and every statistical maneuver to find positive outcomes.

3. Not all practitioners are seasoned epidemiologists. Despite committee guidelines, research editorials and journal reputations, young clinicians must navigate through this data and reflect on its quality and relevance before making a decision to implement its findings in a real-time clinical setting.

An issue with this is that physicians are first and foremost trained to practice clinical medicine; epidemiology and statistics are taught mostly on a participatory basis and often touched upon at a superficial level.  Inexperienced clinicians run the risk of mechanically abiding by recommendations of a study or committee without knowing how to deliberately reflect on the quality of data that is displayed.

4. Not all findings stand the test of time. Although current medical evidence reflects the closest thing we have in our field to certainty, it rarely provides unwavering medical knowledge.  Various recommendations made from clinical research have changed throughout the decades of EBM as new, more rigorous studies can demonstrate conflicting outcomes.

Research regarding the effects of vitamin E on heart health provides a classic example of this.  Decades ago, vitamin E was touted via the results of various epidemiologic studies as an antioxidant that likely reduces stress on the heart.  However many subsequent large clinical studies have failed to find this correlation and also have suggested that there may actually be adverse affects to cardiovascular health in taking this supplement with other cardiovascular medications.

5. Not enough time in the day. It is no revelation to say that a young clinician has many growing pains to endure in his or her first few years or practice.  Developing and maintaining a well-run patient panel, staying on top of local and national quality initiatives and becoming adept at proper documentation, billing and coding are all aspects to clinical practice a fresh physician must keep in mind on a daily basis.

With the little time remaining in a day, these physicians are (rightfully) expected to stay abreast on current research relevant to their respective fields.  However, this poses an issue when a clinician given the sheer amount research currently being published.

An editorial from the BMJ published some time ago explains this unsustainability best:

There are, for example, about 20 clinical journals in adult internal medicine that report studies of direct importance to clinical practice, and in 1992 these journals included over 6000 articles with abstracts: to keep up the dedicated doctor would need to read about 17 articles a day every day of the year.

Take home point

An updated definition of EBM has been suggested as a “systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values.”

Although this is an important revision as it puts the care of the individual patient as priority and incorporates clinical expertise into the mix, emerging physicians, by virtue of their limited patient experience, will often need to depend upon EBM to answer a variety of clinical questions.

Despite the challenges young physicians face with EBM, there are practical approaches that they can take to help incorporate EBM in their practice.

To start, emerging physicians can use various academic resources that help consolidate current research into practical clinical pearls.  This can be in the form of reading through specific organizational task force recommendations, online journal reviews (e.g., ACP’s Journal Club or NEJM’s Journal Watch) and by participating in local journal clubs.  Taking online and community refresher courses on basic statistics can also help solidify basic epidemiological skill-sets required to critically appraise potentially useful clinical studies.

Evidence-based medicine is a valuable approach to clinical practice and should be used with deliberation when incorporating it into daily medical decision-making.  In order for newly-trained physicians to practice EBM, its important for them to understand the challenges they will face in real practice and develop pragmatic strategies to overcome them.

Brian J. Secemsky is an internal medicine resident who blogs at the Huffington Post.  He can be reached on Twitter @BrianSecemskyMD and his self-titled site, Brian Secemsky MD.  This article originally appeared in LeadDoc.

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