Pain Medicine and Management: Just the Facts

Evidence-based medicine (EBM) is a term used broadly often with varying interpretations. In its simplest format, EBM seeks to empower caregivers with the tools to independently evaluate the medical literature and apply those learnings in practice. The term EBM first appeared approximately a decade ago; it has evolved since then. The original focus was to help clinicians preferentially use evidence, when available, from clinical research rather than clinical experience and pathophysiologic reasoning. Over time, practitioners of EBM recognized several important challenges, and as such, EBM evolved. First, clinical experience and pathophysiologic reasoning are forms of evidence, and although more subject to bias, they are often the highest level of evidence available. Second, patients’ preferences and values should be incorporated into clinical decision making. Third, the practice of EBM takes time and often new skills. During the past decade, EBM has made improvements in all three of these challenges. Importantly, many undergraduate and postgraduate programs now provide training in EBM, and on-line training, continuing medical education, and workshops grow rapidly. Moreover, the effort required to find valid evidence has been reduced. Many journals now provide structured abstracts; secondary journals filter biased studies and summarize important clinical studies; the Cochrane Collaboration, which now has an anesthesia section, provides evidence summaries; and finally, textbooks emphasizing evidence-based decision making continue to grow. Evidence-based Practice of Anesthesiology by Fleisher is one such book and a landmark for anesthesiology. It is clearly written and provides a structured approach to clinical decision making. The books 10 sections and 71 chapters are organized around clinical problems. Each chapter includes an overview of the area, a review of the evidence, a summary of areas of uncertainty, and the authors’ recommendation. The last section, authors’ recommendation, is particularly important because much of what we do in anesthesiology and all of medicine is based on clinical experience and pathophysiologic reasoning. The recommendations generally summarize the known evidence, combined with the authors’ experience, to produce clinically useful recommendations. The book achieves a nice balance between being too general and too specific. Traditional text books, which address broad topics, are, in general, great for learning vocabulary and pathophysiology, but they are less good if you want to know “what should I do for this patient in front of me. ” On the other hand, focused clinical queries, endorsed by EBM, that explicitly define a patient population, an intervention, and an outcome pose challenges to organize as a book. The book by Fleisher achieves a balance between the two. Although the book is intended as an evidence summary to aid in clinical decision making, it does not explicitly incorporate patient preferences. Patient preferences and values should figure prominently in preoperative testing and in selecting type of anesthetic. In addition, because of the time to write and publish a book, textbooks of EBM run the risk of quickly becoming dated. Caregivers may need to supplement the book with a recent literature review. The book by Fleisher is balanced, informative, and useful to clinicians who need to make decisions. The book provides clear recommendations, which are informed by evidence and experience, to caregivers. An important future challenge for EBM is to ensure that patients receive the evidence. By grading evidence into “do it or do not do it,” caregivers may be able to concert evidence-based recommendations into performance measures and then monitor whether patients actually receive the evidence that is well summarized by Fleisher. The next step in the evolution of EBM will be to monitor performance and ensure that patients receive the evidence-based interventions they should. In the meantime, caregivers can learn a lot of important information from Fleisher’s text.