The Evidence-Based Medicine Heresy
EBM may be ready for the real world of practice, but is the world ready for it?
Fam Pract Manag. 2004 Feb;11(2):13.
Do you order prostate-specific antigen (PSA) tests for all male patients over a certain age? The best available evidence says that you will do the most good and the least harm in the long run if you don't, but rather explain the pros and cons of measuring PSA levels and follow a shared decision-making model in deciding whether each individual patient has the test or not. Follow that course and you'll have the guide-lines of several well-respected national organizations to support your care: evidence you can bank on. Sort of.
You might be able to take it to the bank, but apparently taking the evidence to court can be dangerous. A recent issueof the Journal of the American Medical Association published the chilling story of Daniel Merenstein, a family physician who ended up facing a malpractice suit because he did just what he was supposed to do.1 As a third-year resident, he saw a 53-year-old, educated patient to whom he carefully explained the pros and cons of PSA testing. He documented the shared decision not to order the test. He never saw the patient again. The patient's next physician, however, ordered the PSA test without discussion; the level was very high, and he was later determined to have incurable, advanced prostate cancer. Merenstein and his residency program were subsequently sued.
A lesson in evidence
In the course of the trial, the plaintiff's attorney successfully made evidence-based medicine (EBM) into "a dirty word," according to Merenstein. "He defined EBM as a cost-saving method and stated his belief that the few lives saved were not worth the money. He urged the jury to return a verdict to teach residencies not to send any more residents on the street believing in EBM." While Merenstein himself was acquitted, the residency was found liable for $1 million. That's a lesson, all right.
If you think the value of EBM is self-evident, Merenstein's experience deserves your close attention. Brandi White's article on page 51 suggests rightly that we're now reaching the point where EBM is practicable in the "real world" of front-line practice. Nevertheless, this court case highlights the degree to which it may not be ready for the unreal world in which most people live. This is the world where gamblers believe they can beat the house, where lotteries are considered a reasonable route to wealth, where probabilities are meaningless, where anecdote trumps evidence every time, where aspirin affects only those parts of the body that hurt, where scientific tests don't lie, where sensitive and specific are the opposites of "unfeeling" and "general," where the number needed to treat is always 1 if it's not just a nonsense phrase, and where no one will believe you could be so heartless as to forgo ordering a test that might help your patient.
The tools and resources of EBM are extremely valuable; they're worth knowing about and worth using, and White's article can help you put them to work. Just don't forget that EBM still has cult status in the eyes of many and that people still occasionally enjoy burning a heretic at the stake.
LAST CHANCE FOR BIG IDEAS THIS YEAR!
This issue contains our last call for entries in the 2004FPM Reader Challenge. As you’ll see from the announcement, we’re looking for practices that have applied big ideas to make big changes.
Entering isn’t hard. In fact, how easy can it get? Your idea doesn’t need to be original with you. You’ve already done the hard part by putting the idea to work. This isn’t even a writing contest. You just need to answer four questions about the idea and what you’ve done with it, and you’re in.
In our September issue, we’ll highlight the entries that are most inventive, most applicable to other family practices and most likely to create better practices, healthier patients and a stronger specialty. Your idea could influence hundreds of practices across the country. Surely, the gratitude and adulation of your colleagues is more valuable than any paltry cash prize, right?
Don’t miss the complete entry information, and think for a minute: Is your practice markedly better in some way than it was a year or two ago? If so, what’s the big idea that gave rise to the improvement? There. You have your entry practically ready to go.
1. Merenstein D. Winners and losers [a piece of my mind]. JAMA. 2004 ;2911: 15-16.
Copyright © 2004 by the American Academy of Family Physicians.
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