To the Editor:
Robert Edsall’s editorial “The Evidence-Based Medicine Heresy” [February 2004, page 13] scared me. As a teacher and practitioner of EBM, I am fully aware that as long as the probability of an outcome is neither zero nor one, there will be the potential for harm using the most rational approach to patient care. Still, your report of Dr. Merenstein’s experience with the lawyer’s demonizing of EBM is worrisome.
But before we start ordering prostate specific antigen (PSA) tests on all males over the age of puberty, we might consider the following scenario. What might have happened if another 53-year-old patient of Dr. Merenstein had a recommended PSA that was elevated, underwent a biopsy that found no evidence of cancer and had a serious complication or died as a result of the procedure? An angry patient or family would probably find a lawyer. If that person were clever, he or she would find information and experts to show that EBM recommendations represented the highest quality of care and that a screening PSA was not a necessary test. I don’t know whether such litigation has actually taken place, but it certainly would be possible.
So what do we do with EBM? Well, if we expect it or any other aid to medical practice to provide certainty, then we probably should be in a different field. It is not heretical to seek and use the best evidence available, as long as we temper it with our own experience, the patient’s wishes and, apparently, the vagaries of our legal system.