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.
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.
The same philosophy applies to medicine practiced in harsh, wilderness environments. Physicians who accompany climbers on Mount Everest would love to have perfect evi- dence 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 emerg- ing 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 difficul- ties. David Sacket, M.D., says, “Half of what you’ll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half.”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 seem- ingly endless debate about what constitutes quality in health- care. 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 cel- ebrating 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 examin- ing 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 preven- tion, 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.
The health profession should not shirk from taking a stand on some of the most provocative issues of our time. Improv- ing 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 be- come 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 pres- sure 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 con- tinuously 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 nu- ances of medical literacy and find ways to face patients with useful prescriptions for information.
I have a few requests for the EBM-based medical com-
munity, 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.
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