Who can argue against evidence-based medicine? Who can argue with using evidence to develop guidelines? The key to practicing great medicine must involve using the best evidence to guide our protocols.
My son, while in college, was an English major. I remember reading his papers. He often used the phrase “on further reflection.” I often recall that phrase when considering these complex issues.
Frederick Nietzsche wrote, “There are not data, only interpretations.” The problem with evidence-based medicine is that medical decisions involve values.
Studies give us important information. They tell us how interventions impact disease, but they also tell us the side effects of the same interventions.
Some interventions are dramatic with minimal side effects. Other interventions modify the course of disease in less dramatic fashion and have greater side effects.
In the second situation, we have to balance the positives and the negatives. Are the benefits worth the risks?
To make these decisions we have to implicitly assign values to the benefits and to the risks. Those values are and must be subjective. Those values are patient specific. For us to declare that everyone should receive a certain treatment implies that we can assign values for everyone.
If this problem was straightforward, then logically we could take the evidence are predictably develop guidelines.
The philosophy of logic demonstrates the inconsistency. We have too many examples of conflicting guidelines. Logically if s were a direct logically product of evidence, then differing panels should develop the same guidelines for the same clinical questions.
But differing panels develop differing guidelines. The only way to explain that phenomenon is to understand that evidence is never absolute. We must always interpret the evidence, and our interpretations involve values.
Thus too often our guidelines should not be rules. They are often not patient oriented. We cannot explain these observations otherwise.
The guideline movement is out of control. We are bombarded with long complex guidelines that address problems in a paternalistic fashion.
We need shorter, more focused guidelines. We need the honesty to provide the probability of benefits and risks. Guidelines should help us frame medical decisions for our patients. Guidelines should give us a framework. Guidelines are not, and should not be, rules.
We need to all understand that evidence requires interpretation and thus the evidence does not imply the same answer for every patient with the specific situation.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
