Evidence Based Medicine Vs. Intuition
I happened to read this interesting article here (Evidence-Based Medicine: What’s the Evidence? http://onlinelibrary.wiley.com/doi/10.1002/clc.21968/full) on Evidence based medicine and re-appraisal of its evolution and growth to becoming the centrality of medical practice. Medicine has always depended on empirical evidence (as has science- despite what the creation science/intelligent design supporters say) but only recently has the concept of evidence based medicine become absolutely indispensable to the everyday practice of medicine beating out clinical acumen, clinical experience and that most elusive of holies- gut feel.
Don’t get me wrong…I love evidence based medicine- despite the fact that my professors in my PG years made me learn by heart the top 100 authors/ researchers (of best articles) in my specialty and their areas of current research and any paradigm altering scientific evidence they produced….you could have woken me up in my sleep and I would have told you what Dr’s Beverly Dale, Kolebrander, Isao Ishikawa were up to till the previous week…but that didn’t make me an expert on evidence based medicine- it was purely exam oriented training.
But as I started my research works for my master’s thesis and I came into contact with research methodology and those twin towers of medical research- “p” value and odds ratio- I felt the first twinges of disquiet. As the eminent researcher K.A.Fisher pointed out – statistics are just probabilities – they are not certainties and the whole edifice of medicine was based on these research papers as if they were the infallible truth. With the advent of internet medicine and patients armed with reams of printouts from dubious medical websites, we are often forced to practice safe medicine- go for the most defensible prescription- always keeping in mind a potential lawsuit in the future (years later -when we have forgotten all about it).
It wasn’t always like this. When I was young and getting my usual quota of childhood diseases- we alternated between two doctors to treat my childhood ailments. One was a famous General Physician called Dr.Venkatesh Pai of George Town, Madras, a schoolmate of my grandfather (in the 1930’s)– who had treated my grandfather, my father and when he finally came down to me- he was the very definition of a family doctor- old, wizened, wise and absolutely authoritative. Patients used to wait in droves outside his palatial bungalow cum clinic and he used to dispense his own compositions- the compounder at the attached pharmacy handed out colored bottles and powders of unknown provenance which used to work wonders- mainly because patients believed that he had the special “gift of the hand”- the Rashi of curing any patient he saw….a placebo belief which was more powerful than any medicine he dispensed.
The other doctor my parents used to take me to was for emergencies- a brash young Paediatrician just starting to make a name for himself in the profession, a Dr.Vishwanath of Nungambakkam, Chennai who was a great believer in symptomatic treatment, in reducing high-fevers in no time, with anti-pyretic injections and corticosteroids. When I started my own clinical practice I begun to understand his line of treatment better- as parents insist on and expect nothing less than immediate success when it comes to children- they don’t appreciate the take this medicine and wait for it to work line. Like every recently graduated doc, he plied me with all the latest drugs on the market- stuff which my other physician would never ever consider. Between these two extremes of treatment, I somehow survived unscathed and lived to write this post.
My next brush with the (un)certainties of modern medicine came when I was in Tanjore Medical College. I used to hang out with a bunch of Oto-Rhino-Laryngologist’s, better known as ENT Surgeons (in fact, I was dating one of them – a PG student which gave me privileged access to the inner sanctum) and I used to hear a lot of gossip about current advances in their specialty. The ENT docs considered Adenoids/tonsils and all accessory lymphoid tissues as purely vestigial and were forever recommending their removal…So much so, that a standing joke among the other doctors was that ENT docs don’t do surgery for tonsillitis (the disease) but for tonsils (normal). This was purely based on current Evidence Based Medicine which said that you don’t need your tonsils for normal, everyday life (along with appendix/wisdom teeth etc)- which gave a fillip to the cut it and throw it out group. This again prompted me to have vague doubts about the vagaries in interpretation of evidence based medicine.
The point I am trying to make is if the practice of medicine was just about writing out a prescription- based on current available best evidence – given a set of symptoms…then any robotic interface can do a better job than even the best trained human. It’s that intangible something called clinical experience, acumen or gut feels which separates robotic medicine from human medicine. For example antibiotics like Co-trimoxazole or Erythromycin have never gone out of circulation, but is there any recent prescription where you have seen them? I have not. The bad reputation these drugs have acquired as becoming ineffective or susceptible to resistant organisms is purely word of mouth gossip over conference lunches and canteen coffees. And practioners have moved onto newer generations of antibiotics for even simpler infections precisely because they have faith on them based on the grapevine rather than any hard evidence or double-blind, gold-plated RCT studies. And of course, when compelling evidence shows us clearly what works or not- we do accept it and change promptly.
So, tell me all, is your practice based solely on best evidence or do you give credence to your inner voice? Your experience, your acumen, your gut-feel when it comes to deciding what works or maybe will work better for that particular patient?
(P.S. this post is based on personal beliefs and is being published on a personal blog in my personal capacity- and not in a peer-reviewed, indexed journal- hence I don’t have to produce voluminous, hard data, to substantiate my beliefs which I stated here…feel free to comment and I will reply..If you feel the need to debate-please excuse)
(P.P.s. Pics courtesy Google Images)