How Evidence-Based Medicine Will Change the Way You Practice

Article excerpt

See what our roundtable of experts and practitioners has to say about the ways this rigorous new approach will affect doctors.

Strongly supported by the US medical establishment, evidence-based medicine has become a focal point for those who wish to infuse more sci

Evidence-based medicine is "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients," according to David L. Sackett of Oxford University and other leading proponents. To practice evidence-based medicine, a doctor must combine study results with his own clinical judgment and patient preferences. The hoped-for outcome: significantly improved quality of care.

Of course, this is a tall order. For one thing, no more than half of what doctors do is supported by rigorous scientific evidence. And it's impossible for even the most dedicated physician to keep up with all of the new studies coming out.

Aside from the practical difficulties, some physicians reject the idea of changing how they practice on the basis of even the best studies. They variously argue that science can't predict the pathophysiological behavior of individual patients; that there's uncertainty in applying even the most carefully validated medical evidence to individuals; that randomized controlled trials are often conducted on patients who aren't similar to those seen in practice; and that the results of these trials apply to the average patient with a certain condition, not to subgroups with particular clinical features.

To illuminate this controversy, Medical Economics assembled a panel of doctors in New York City. Included were three fulltime family physicians-Charles Davant III, Patricia Roy, and Gil Solomon-and two nationally known experts on health care quality-internists Robert Brook and David Nash. (See facing page for more details on the panelists' backgrounds. Managed Care Editor Ken Terry moderated the discussion.

Moderator: To what extent should a doctor treat patients according to the best scientific evidence, in cases where that evidence seems to apply?

Patricia Roy, DO: We should always do that. But we may not be able to in all cases. The art of medicine consists of identifying people to whom a particular study applies, and, more important, identifying those to whom it doesn't.

Moderator: How do you decide whether the evidence in a particular study is good enough to apply to the patient in front of you?

David Nash, MD: At the physician office level, it's not a matter of deciding which article to believe. The real issue is that if you're a diabetic in the United States, the probability that you'll get your feet and retinas looked at annually is less than 50 percent. Though we've got very good evidence about what works and what doesn't, we have very poor tools to apply what works, especially in the office setting.

Another challenge is that we're being asked, under a new payment system, to care for a population of patients and be accountable for that population. How do we balance individual needs against the economic incentives we have to care for a population?

Robert Brook, MD: What's occurring is the beginning of a radical transformation in the way we practice medicine. But it has a long way to go. No doctor wants to ignore evidence-based medicine in making decisions about patients, yet we do so way too often, because we can't keep up with the explosion in clinical knowledge.

Our clinical database also has some severe limitations. For instance, we haven't included the elderly in most of our randomized controlled trials. We also haven't included children. About 80 percent of what's recommended for the treatment of children is based on non-randomizedtrial evidence. That doesn't mean the evidence is worthless. It's just not the highest form.

Gil Solomon, MD: I find it very difficult to practice evidencebased medicine, because it's very time-intensive to stay current. …