Con: should evidence-based medicine be used more in clinical practice?

The California Journal of Emergency Medicine VII:1, Jan-Mar, 2006 Page 17 Con: Should Evidence-Based Medicine Be Used More in Clinical Practice? Preston Maxim, MD Department of Emergency Medicine San Francisco General Hospital San Francisco, California A junior resident begins treatment of an elderly woman in the Emergency Department, who complains of severe epigastric abdominal pain for the last 6 hours with associated fever and vomiting. She has a rigid abdomen with diminished bowel tones, guarding and rebound. She is requesting pain medicine, but the resident refuses to give her any medications perhaps recalling the dogmatic teaching of his surgical attending, who claimed it would “mask” the etiology of her pain. When I came to see my mother-in-law 6 hours later, she remained in severe pain in spite of having a clear diagnosis of gallstone pancreatitis, based on physical, laboratory and ultrasonographic findings, and still had not received any pain medication. This in spite of a pantheon of articles finding that pain medication either improves or doesn’t change the sensitivity of physical exam findings in patients with abdominal pain. Clearly, evidence-based medicine needs to be used more in clinical practice, but there are limits within the Emergency Department. In medicine one must pay attention not to plausible theorizing, but to experience and reason together… Conclusions drawn from unaided reason can hardly be serviceable. —Hippocrates It is hard to believe that anything written now will have as much sustained relevance in medicine as the writings of Hippocrates nearly 2500 years ago. Prior to the advent of evidence-based medicine, medical practice was “plausible theorizing” based on a combination of knowledge of pathophysiology, clinical experience and common sense, a practice sometimes referred to as “authority-based medicine.” The practitioner arrived at a diagnosis based on history, physical exam and diagnostic reasoning, and when the diagnosis or treatment course remained unclear, the clinician reflected on the applicable pathophysiology of the disease, or sought the counsel of a teacher/expert in the field. Historically, the “authority-based” approach led to significant improvements in patient care and treatment regimens; however, it also produced significant clinician-based variations in patient care. Evidence-based medicine allows the comparison of different clinician-based treatment approaches and suggests which of them provide the best patient outcomes. Amongst the issues that have been examined is whether the use of analgesics in patients with abdominal pain masks the etiology of the pain. In fact, this issue has been addressed a number of times and the preponderance of evidence refutes the admonition against the use of analgesics in patients with significant abdominal pain. 1-4 The integration, albeit slowly, of this evidence and other evidence-based evaluations of clinical care has led to significant further improvements in patient outcomes. Ever since the phrase “evidence-based medicine” was defined in a 1992 JAMA article entitled “Evidence- based medicine: a new approach to teaching the practice of medicine,” there has been significant pressure to integrate “evidence” into clinical practice. 5 This has led to a relative explosion of clinical diagnostic and treatment guidelines and algorithms in the medical literature. Concomitantly, residency programs have begun to actively promote evidence-based training as a way to optimize patient care. Prior to completely abandoning the teachings of “authority-based” medicine, however, it is important to remember that there are significant issues with practicing medicine from a purely evidence-based standpoint. First of all, evidence-based medicine primarily focuses on the integration of randomized clinical trials and meta-analyses into clinical practice; however, not every clinical issue is significant enough to warrant a randomized clinical trial and other issues will never be examined in a randomized clinical trial for consent reasons. It is unlikely, for example, that a clinical trial comparing treatment modalities for chronic immersion foot in the homeless will ever be attempted, though