The burden of evidence

Evidence based medicine has advanced our science and helped doctors move from inconsistent, often unsupported, practices based on our last case and anecdotal experience to more uniform, effective care. Rigorous methodology has facilitated efforts to deliver high quality treatment and improve outcomes for large patient populations. We have elevated the science published in journals and presented at meetings. Elegant randomised controlled clinical trials, meta-analyses, and guidelines have changed the support of our recommendations from “because I said so” towards “because we know so.” Cost analyses have provided means to allocate our tightening resources efficiently and allow doctors and health systems to survive in an era of intense financial pressure.

We must trust our own knowledge and individual “expert opinion”

However, in the wake of these achievements, the burden of evidence based medicine may have untoward effects on relations between patients and doctors, on personal satisfaction, and on artistic components of the “art of medicine.”

Doctor scientists at all levels have a natural curiosity for “proof” that fosters a healthy scepticism of the latest breakthrough in medicine or technology. Our inquisitive nature and investigative tendencies are fostered early in our medical education and serve us well. We are taught to recheck each laboratory value, to scrutinise written reports, and to furrow our brows at the care delivered by the last provider who saw our patient. This philosophy has helped protect our patients from potentially harmful new drugs, trendy herbal treatments, or medical devices ordered on late night television.

Yet, I fear that our search for certain proof has eroded valuable components of care. Taking time with patients, handholding, explaining, comforting, listening, providing hope, and taking interest in our patients' lives are becoming passé in the evidence based revolution of medicine. These lost arts were the mainstay of practice 100 years ago. Our colleagues of past centuries often used foolhardy, unproved, and, occasionally, outright dangerous measures to combat disease before the availability of antibiotics, antidepressants, and antihypertensives.

However, our predecessors often realised the limitations of their medicine and spent time in activities that we no longer esteem because they are not supported by evidence in a peer reviewed publication or the Cochrane collaboration. We presume that we are better doctors with all of the new tools of science. But I am not so certain. In some aspects we seem to be deficient. With new yardsticks of evidence based medicine we have quickly abandoned vital aspects of medicine that are the most difficult to teach, to measure, and to explain.

I find myself struggling with existentialist questions of my professional life. If there is no proof that my 30 minute health maintenance visit works should I stop seeing my patients regularly? Should I really schedule them back in three months for a follow up visit? Did the extra five minutes talking about their most recent family outing and personal interests improve their survival? Will my safety and preventive medicine counselling reduce utilisation and expenditure? Is my routine physical examination of the asymptomatic patient sensitive and specific? Can I justify my value to my hospital system and to my patients' insurers? Often the evidence based answer to most of these questions is not clear or “incomplete evidence.” Somehow in our lust for hard data, these unknown answers have transformed into “no.”

If there is no clear and convincing evidence the default mode is to view the practice as worthless. Hospital cuts and denials of payment have used this approach to ruthlessly pare away activities without the impossible, often unattainable burden of proof. We are now “guilty until proved innocent” of practising archaic, inefficient medicine if we cannot justify each minute of our activity.

I believe that the “burden of evidence” is threatening our professionalism, interactions between patients and doctors, and career satisfaction. Certainly, we must strive to develop better outcome measures and qualitative methods to capture the humanistic aspects of healthcare delivery that are challenging to quantify. However, there will undoubtedly be many subtleties of our care that will never be validated by p values. We must continue to embrace this valuable side of our art. A lack of evidence in absence of harm cannot be interpreted as useless or futile. There will often be individual cases and components of our care that we personally deem important and valuable.

In the absence of clear harms or evidence against these practices, we must trust our own knowledge and individual “expert opinion.” The values of peace of mind, understanding, and comfort for our patients and ourselves cannot be discounted and discarded in the era of modern evidence based medicine.