Seven alternatives to evidence based medicine

Clinical decisions should, as far as possible, be evidence based. So runs the current clinical dogma.¹,² We are urged to lump all the relevant randomised controlled trials into one giant meta-analysis and come out with a combined odds ratio for all decisions. Physicians, surgeons, nurses are doing it^3–5; soon even the lawyers will be using evidence based practice.⁶ But what if there is no evidence on which to base a clinical decision?

Participants, methods, and results

We, two humble clinicians ever ready for advice and guidance, asked our colleagues what they would do if faced with a clinical problem for which there are no randomised controlled trials and no good evidence. We found ourselves faced with several personality based opinions, as would be expected in a teaching hospital. The personalities transcend the disciplines, with the exception of surgery, in which discipline transcends personality. We categorised their replies, on the basis of no evidence whatsoever, as follows.

Eminence based medicine—The more senior the colleague, the less importance he or she placed on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence. These colleagues have a touching faith in clinical experience, which has been defined as “making the same mistakes with increasing confidence over an impressive number of years.”⁷ The eminent physician's white hair and balding pate are called the “halo” effect.

Vehemence based medicine—The substitution of volume for evidence is an effective technique for brow beating your more timorous colleagues and for convincing relatives of your ability.

Eloquence based medicine—The year round suntan, carnation in the button hole, silk tie, Armani suit, and tongue should all be equally smooth. Sartorial elegance and verbal eloquence are powerful substitutes for evidence.

Providence based medicine—If the caring practitioner has no idea of what to do next, the decision may be best left in the hands of the Almighty. Too many clinicians, unfortunately, are unable to resist giving God a hand with the decision making.

Diffidence based medicine—Some doctors see a problem and look for an answer. Others merely see a problem. The diffident doctor may do nothing from a sense of despair. This, of course, may be better than doing something merely because it hurts the doctor's pride to do nothing.

Nervousness based medicine—Fear of litigation is a powerful stimulus to overinvestigation and overtreatment. In an atmosphere of litigation phobia, the only bad test is the test you didn't think of ordering.

Confidence based medicine—This is restricted to surgeons (table).

Comment

There are plenty of alternatives for the practising physician in the absence of evidence. This is what makes medicine an art as well as a science.

Table.

Basis of clinical practice

Basis for clinical decisions	Marker	Measuring device	Unit of measurement
Evidence	Randomised controlled trial	Meta-analysis	Odds ratio
Eminence	Radiance of white hair	Luminometer	Optical density
Vehemence	Level of stridency	Audiometer	Decibels
Eloquence (or elegance)	Smoothness of tongue or nap of suit	Teflometer	Adhesin score
Providence	Level of religious fervour	Sextant to measure angle of genuflection	International units of piety
Diffidence	Level of gloom	Nihilometer	Sighs
Nervousness	Litigation phobia level	Every conceivable test	Bank balance
Confidence*	Bravado	Sweat test	No sweat

^*Applies only to surgeons.