The conundrum of clinical medicine is what makes it difficult

The term, “evidence-based medicine” (EBM), provokes strong feelings from its proponents and its skeptics.  I spent a full day recently in discussions about EBM.  As the day proceeded I understood that evidence is wonderful when it fits the clinical question, but that too often the clinical question does not, and probably will not have adequate evidence.

We have great evidence for some clinical questions.  We all know that ACE inhibitors decrease mortality in patients having systolic dysfunction.  We know that antibiotics help a variety of documented infections.  We know which biologically active DMARDs improve the course of rheumatoid arthritis.  We know that home oxygen decreases mortality in chronic hypoxic patients.

But how many clinical questions lack such specificity.  My recent clinical passion — the Lemierre syndrome — has no evidence for prevention or treatment.  We must make decisions about empiric antibiotics for severe sore throats in adolescents and young adults, and we must choose antibiotics in a patient diagnosed with the syndrome.  We do not have, and likely will not have randomized controlled trials (RCTs) to guide our management.  Rather we must use clinical judgment.

Believing in EBM does not and should not eschew faith in clinical judgment.  Many clinical situations do require judgment.

Even if one believes in EBM, controversies among guidelines must give one pause.  These likely occur because differing guideline committees have differing priorities and values.  Data are not cold hard facts that we can always apply to our patients.  Rather we must filter data through a screen of patient preferences, co-morbidities and social concerns (including money).

Medicine is a challenging career, because we must always meld our scientific knowledge with our art.  Yes, the art of medicine and the science of medicine are not, and should not be considered separate entities.  Every clinical decision must relate to the patient’s context.  When we have performance measures that do not consider those contexts, then the measurement developers are actually impacting our decision making, and often in a negative manner.

Clinical medicine is difficult.  We oversimplify medicine when we think that rules can always substitute for judgment.  This is our conundrum.  When the evidence and the patient conflict we physicians have unease, especially when someone is judging our decision making without understand the underlying patient context.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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