Clinical Information Systems
Getting the evidence
The challenge of implementing evidence-based medicine in tough global environments.
By Paul S. Auerbach, M.D., December 2012
Paul S. Auerbach, M.D., FACEP, FAWM, is a professor of surgery at Stanford University School of Medicine. For more on Elsevier: Elsevier
Healthcare needs evidence-based medicine (EBM) to move forward with new and emerging opportunities, ranging from personalized medicine, chronic disease management and patient engagement to medical home, accountable care and population health management.
However, as clinicians and researchers make progress on EBM, they should also consider the needs and capabilities of physicians who were educated without the latest and greatest technologies, or those who practice where resources are scarce.
Doctors find themselves in difficult environments more often these days. They can be on a mountainside or far out at sea practicing wilderness medicine, in a global humanitarian relief situation or even in the midst of a disaster. They can also be in a busy office practice, where time has been shortened for individual patient encounters and expectations for productivity run high. While medical professionals and health advocates are committed to offering the pinnacle of care to all patients, doing so isn’t always realistic or possible.
Currently, EBM rests at a unique intersection of circumstances. Where the circles of accepted data, clinical experience and an improved situation in the eyes of the patient intersect, there emerges EBM. We can all agree that EBM is not simply having the latest facts taken out of context for the situations of the patient and practitioner. A truly difficult global location or circumstance further complicates the situation.
Imagine that you are practicing medicine on an isolated mountainside or far out at sea. Undoubtedly, there is evidence to be used, but unless it is at your fingertips precisely when you need it, the medicine practiced in these environments tends to be the best medicine one can muster. Constrained by limited resources, this brand of medicine can be grounded more in compassion and practicality than in clinical decision rules. Traditional data collection usually suffers, so observations may become more important and improvisation emerges as an indispensable clinical skill. This is not “silver platter medicine,” where the patients come to their providers with an adequate past medical history and reams of data, and there are enough helpers flocking to allow the luxury of downsizing the team.
Environments considered challenging to privileged urban practices include impoverished and underserved patient populations, working within an underdeveloped or dysfunctional nation and combat exposure. Challenges that are present in safe places are increasingly inadequate time and resources to develop relationships with patients and also keeping up with advances in medicine. In difficult environments, physicians discover the importance of three factors: clinical experience, intuition and common sense.
Furthermore, what’s the value of experience? You know, the good old-fashioned kind, where the older you get, the wiser you’re supposed to become. When I presented this thought at a recent conference (“Transforming Healthcare Through Evidence-Based Medicine, a CMIO Leadership Forum”), I saw a lot of the CMIO heads in the audience nod in acknowledgement. With the rush to EBM and electronic medical records (EMRs), we are in some sense redefining our identities and our future as doctors.
For example, following the 2010 earthquake in Haiti, I was working in Port-au-Prince and watched a strict, evidence-based approach argue against caring for many patients with extraordinarily serious injuries. For the most part, the standard rules of triage applied. Not surprisingly, there were exceptions. Convinced that a middle-age patient with a severely crushed and mummified leg would die, well-meaning surgeons declined to operate on him for a few days, and tirelessly labored around the clock to save other persons who were predicted to have better outcomes. They looked at his leg more than his heart. But we insisted that the patient had a strong will to live, and he showed the surgeons an infectious smile. So, they changed their minds and agreed to amputate his leg. After the surgeons saved his life, the patient eventually was able to walk on crutches out of the hospital. In this situation, and in many others like it, EBM is impractical to apply. In the medical response to the earthquake in Haiti, EBM was substituted with what I was taught by my mentors as a medical student in the mid-1970s: the best well-intentioned evidence culled from a lifetime of experience studying medicine and caring for patients.
The same philosophy applies to medicine practiced in harsh, wilderness environments. Physicians who accompany climbers on Mount Everest would love to have perfect evidence about the best ways to treat mountain sickness and other high-altitude-related illnesses. But mountain medicine being what it is, there are a lot of opinions and slowly emerging facts. Difficult environments (Haiti and Everest, for example) raise questions about how best to practically apply evidence while not losing sight of doctoring attributes, such as clinical knowledge, experience, intuition and common sense. The data generated by reviewing flawed studies in order to generate an EBM recommendation compounds the difficulties. David Sacket, M.D., says, “Half of what you’ll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half.” If we can only be certain of half of what we learn, what does that say about how sure anybody can be about the evidence? We should judge, but not rush to judgment.
Perhaps the most difficult environment of all is the seemingly endless debate about what constitutes quality in healthcare. It will take many years and an army of researchers and statisticians to find consensus. Perhaps we in medicine need to modify somewhat the perspective, or at least the methods of introduction, of EBM.
Let’s never lose sight of providers. We can’t afford to have them demoralized. We spend a lot of time appropriately celebrating the gold medal winners who have advanced science, but we need to find an equally meaningful way to recognize the folks in the trenches. Do we want clinicians to spend their precious time learning how to navigate an EMR, or do we want them with their hands, eyes and ears at work examining patients and guiding their care? If you live in a developed country, you’re pretty well off compared to people who are starving. Unrealistic as it may sound, we should concentrate less on medical advances at the margins and more on prevention, health promotion and wellness, while bringing the entire receptive world up to decent medical standards by eliminating preventable childhood diseases, ending war, reducing poverty and protecting the environment.
ClinicalKey can help physicians mine current research from journals and articles published around the world.
The health profession should not shirk from taking a stand on some of the most provocative issues of our time. Improving the quality, safety and cost of care hinges on developing evidence to answer questions such as these:
- What is the impact of changes in the natural environment on human health?
- How can healthcare implement a moral, compassionate approach to dying while avoiding the ICU?
- How does adequate funding for healthcare research become a national priority?
- Do our leading politicians get their counsel from persons knowledgeable about healthcare and the doctor-provider relationship?
As healthcare organizations work to promote evidence-based practice, they must also support clinicians in their multiple roles as lifelong learners, team players, champions of standards and rules, system innovators, quality and safety experts, and advocates for patients and the public. Of course, with more and better evidence, physicians are under pressure to know everything all of the time. Technology is going to play a large role in helping physicians cope with that data deluge. EMRs (both for physicians and hospitals), predictive tools that analyze all the “big data” on populations and clinical reference tools (particularly those that can be integrated into the workflow and brought effectively to the point of care) can help physicians quickly mine the current research residing in hundreds of medical journals and articles published around the world. Large, effective collections of current information, such as ClinicalKey (see example on next page), that continuously strive for ease of use, comprehension, global reach, impact and relevance will be part of the essential foundation. Other goals should be to allow practitioners to easily share clinical knowledge with their colleagues, recognize the nuances of medical literacy and find ways to face patients with useful prescriptions for information.
I have a few requests for the EBM-based medical community, including researchers, chief information officers, healthcare organizations, associations, medical schools and think tanks:
- Share stories that make EBM relevant to physicians. Bring EBM to where the providers live.
- Create forums to discuss errors that emanate from EBM. Legendary clinician Dr. Eugene Stead reportedly said, “The accurate recording of inaccurate data is not a useful pastime.” Mistakes will be made.
- Present positive visions for the future of medicine.
- Encourage physicians to function as artisans, not assembly line workers.
- Take on tough global issues. Make social responsibility the heart and soul of medicine.
The medical profession is dedicated to making the world a better place. If we allow EBM to be a facilitator in removing uncertainty while retaining the framework in which healthcare providers can heal and nurture their patients, it will be greeted with enthusiasm and gratitude.