Abstract
The concept of using evidence-based strategies as the basis for professional activity has become the centerpiece for assessing the quality and validity of health care. Clinical guidelines and performance standards are created on the available evidence base and are disseminated for adoption and use. It is assumed that the creators of the guidelines have incorporated the most current and complete information on a particular topic and have distilled it into the “best” practice for a particular condition based on the current evidence. Swenson et al. 1 examined the evolution of medicine and medical practice beginning with the thesis that the health care system in the United States is broken, and has failed to adopt many of the tools that have transformed and modernized other industries. They describe the current health care system as a “cottage industry of non-integrated artisans who eschew standardization” while providing variable care that is customized to individual patients. Swenson describes the necessary transformation of health care delivery as follows:
In the past, a stereotypical good doctor was independent and always available, had encyclopedic knowledge, and was a master of rescue care. Today, a good doctor must have a solid fund of knowledge and sound decision-making skills but also must be emotionally intelligent, a team player, able to obtain information from colleagues and technological sources, embrace quality improvement as well as public reporting, and reliably deliver evidence-based care, using scientifically informed guidelines in a personal, compassionate, patient-centered manner. Modern physicians should welcome guidelines covering the basics of evidence-based care, which can free them to focus on the complex issues that require their training and expertise. 1
These authors believe that the application of improvement tools is not only essential to modernizing care delivery, but is also the key to preserving the values that the current system aspires to emulate. 1 It is not surprising that the mantra of providing evidence-based care with scientifically informed guidelines hinges on the systematic, system-wide assessment and analysis of the scientific literature rather than on the ongoing use of observational or experience-based strategies. These authors also recognize the fact that whereas unscientific and unwarranted variation in practice is potentially injurious and costly, the “undiscerning enforcement” of even excellent guidelines can be dangerous to patients with complex multisystem diseases or other valid contraindications. 1 This latter point is often the crux of the arguments on both sides regarding the widespread adoption of clinical guidelines. Swenson and others would argue that guidelines are suitable for the majority of patients, whereas their more traditionalist opponents would argue that individual patients with contraindications or other mitigating circumstances are the rule rather than the exception.
There is some merit to both arguments. Both would perhaps differ on their definition of an expert. However, they would most likely agree that the quantity of scientific information available and the knowledge base is expanding at a rapid rate. Current data indicate that there were 25,400 journals in science, technology, and medicine, which accounted for 1.5 million published articles in 2009. 2 The number of journals is increasing at a rate of 3.5% per year and PubMed now cites more than 20 million papers. 2 These statistics underscore the fact that even the most well-intentioned, avid reader is physically unable to narrow the gap between what he or she can learn versus what is known on any given topic. There is a similar problem with reliance on systematic reviews, as they may not be up to date, and there is an increasing probability that they may promote misconceptions as a result of erroneous reporting of misinterpreted or improperly cited material. 2 –4 There is also the sometimes overlooked fact that many clinical topics simply do not have systematic reviews available and that up to 75% of interventions do not have a firm evidence base. 3 Similarly, randomized controlled trials may produce contradictory findings and may not reflect “real world” patients, because of selection or interpretation biases, or other inclusion or exclusion criteria. 2,4
Dalzell 4 points out that there are several problems with the evidence-based medicine mantra. He contrasts the thinking of several authorities and reminds the reader that no system is perfect and that scientific evidence has a short lifespan in many cases. There is also the admonition to resist the temptation to disregard information solely on the basis of its source of funding, as bias and special interests in study outcomes are also inherent in academic research. 4
Vacillation in recommended practices based on “the evidence” is arguably more commonplace than we care to recognize. Consider such topics as vitamin D supplementation, calcium supplementation, recommendations regarding caffeine, hormone replacement, or the latest fad in diet and weight control. Both Dalzell 4 and Swenson 1 support the concept of careful use of observation and experience in the interpretation and use of evidence. This common sense approach is arguably the full circle recognition of the fact that being an expert depends upon much more than the ever changing scientific evidence and requires learning from experience. Dalzell suggests that observational studies should be viewed with greater credibility in the context of our current imperatives. 4
It is seemingly more apparent that the more we seek to know about something and the more that we change our practice based on the most current available evidence, the more some things will remain the same. So too will our thirst for knowledge, discovery, and truth.