Evidence-based Medicine: A Framework for Emotional Regulation, Intuition, and Conscious Engagement

“Without clinical expertise, practice risks becoming tyrannized by evidence.”

—David Sackett¹

Even though most people—including scientists—use intuition every day, clinicians are advised to stick with evidence-based medicine and for the most part steer clear of spirituality, consciousness, and intuition. This is changing as scientific evidence emerges to support the notion that the practice of good medicine includes attention to these factors. In fact, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the organization that sets standards for healthcare institutions, requires organizations to include a spiritual assessment as part of the overall assessment of patients,² an acknowledgement that both science and spirit provide important contributions to optimal health.

As health and wellness emerge as healthcare priorities, there is recognition that spirituality and science are not mutually exclusive. It helps that there is a body of science that point to benefits of spirituality on health. Associations have been found with reductions in mortality, hypertension, HIV progression, cognitive decline in Alzheimer's disease, substance abuse, gambling, depression and anxiety, and more.³ Yet randomized controlled trials and systematic reviews, the arbiters of evidence designed to evaluate pharmaceutical drugs and medical devices for specific indications, are the dominant focus in today's healthcare system.

Evidence-based medicine is immensely important in bringing science to the bedside. It involves a powerful four-step framework in which healthcare providers (1) frame the right clinical questions to begin with, (2) find the best available scientific research to answer those questions, and then (3) evaluate and (4) apply the research to make the best possible healthcare decision with their patients (Figure). The process in clinical practice then loops back to frame the next question: “How did that work out?”^4–6

Figure.

Four-step framework for bringing science to the bedside.

While evidence-based medicine helps us apply scientific answers to address our health concerns, this alone may not be enough to facilitate our experience of optimal health and healing. Indeed, the reliance on databases, electronic health records, and other forms of technology has the potential to sterilize the physician-patient interaction. If a sense of wholeness and one's spirituality is related to the experience of health and well-being, how do we include the willingness to be inspired, to open our hearts and feel compassion, and to experience love, hope, forgiveness, inner peace, stillness and comfort?

One of the pioneers in evidence-based medicine, Archie Cochrane, recognized that science alone was not enough. In his book, One Man's Medicine,⁷ he shared how as a doctor in a prisoner of war camp he cared for a dying patient who he initially believed was screaming in pain from pleurisy. With no medications at hand to care for the patient, he simply held the patient in his arms and noted that the screaming stopped almost at once. He recognized that loneliness, not pleurisy, was likely the cause of the screaming and that the needed balm was love and compassion rather than morphine.

So how can we become more conscious about integrating a spiritual dimension, love and compassion, with science on the journey to health and wellbeing? After writing a textbook on evidence-based medicine,⁵ I dedicated more than a decade to training healthcare providers in this practice and then began to slip into despair. For me, the science-focused approach I was teaching represented the mind of medicine and I was sorely missing the heart of healthcare from my earlier work around healthcare provider resiliency and well-being and the compassionate delivery of healthcare.

Five years ago, while putting my 4-year-old son to bed and restlessly contemplating my career path, I had a life-changing event. A question popped into my mind: “How can I find my way home?” And in that very moment I found a sense of peace and calm I had never experienced. In reflection, I realized that all I had done was to ask a better question. Instead of self-critically asking, “How could I have veered off track?” I had asked a self-compassionate question, “How can I find my home?”—a place where I felt whole. It dawned on me that I had spent the last decade training healthcare providers in a framework that also begins with asking the right questions.

I then appreciated the larger blessing of my foray into the world of evidence-based medicine—how it has much to offer as a framework for spirituality itself (which for these purposes I simply define as the willingness and capacity to be inspired). In addition to helping bring science to the bedside as a spiritual process, these four steps can also help healthcare providers and health seekers alike to:

1. Frame meaningful questions that are inspiring and constructive in our lives.

2. Find more inspiring answers by creating an optimal brain state using what we know around the neuroscience of emotional regulation to create optimal brain coherence. The article by Barbara Lutz in this issue speaks to the power of this process.⁸

3. Evaluate the answers we discover to ensure they feel right more than they feel good as well as in alignment with our highest values and deepest intuition. This connects to the importance of intuitive intelligence referred to in the article by Rollin McCraty and Maria Zayas.⁹

4. Apply the answers we trust by engaging in conscious and purposeful action in our lives. The process then loops back to frame the next question: “How did that work out?”

Just as the framework of evidence-based medicine enables us to navigate scientific uncertainty, this framework may also serve us in navigating existential uncertainty to more fully cultivate health and healing. Given that the root of the words health and healing comes from the Old English hāl, which means wholeness, it's inspiring to discover that the framework of evidence-based medicine may offer a unified approach for integrating science and spirituality on our global quest for advancing the delivery of health and medicine.

Biography

Daniel Friedland, MD, ABIHM, serves as the chairman of the Academy of Integrative Health and Medicine. A graduate of medical school at the University of California in San Francisco, he is an internist by training. Dr Friedland is the author of Evidence-Based Medicine: A Framework for Clinical Practice as well as a coauthor with his 14-year-old son Zach of The Big Decision—sharing a story around how the framework of evidence-based medicine can be used to make better life decisions. Daniel is the president and chief executive officer of SuperSmartHealth (San Diego, California), which integrates the framework of evidence-based medicine into executive leadership and physician resiliency programs and coaching. For more information, visit SuperSmartHealth.com.