Are We Giving Bad Advice?
Hi, I'm Dr. John Shim, and today I'd like to talk about a rather boring topic, and that's the discussion about evidence based medicine. To many this seems like a buzz word, or a way to justify certain treatments. In reality, evidence based medicine is the more modern way to determine if clinical decisions are based on supporting scientific data instead of just pure tradition and medical art form. While I'd like to say that the current modern medical treatments are based on scientific data, the reality is many of the accepted practices are based on community standards. While they maybe had some sound reasoning for doing these community standard treatments, unfortunately, it's hard to know if these community standards are actually based on scientific data. Let's give an example, in reality the use of antibiotics for many common respiratory conditions is probably counterproductive, and may potentially cause more issues in the future. While bacterial infections can be eradicated by antibiotics, the right antibiotics must be chosen. If the infection is a viral one, antibiotics will not do anything to help that situation. The reality is antibiotics have been over-utilized, and as a result there are now many resistant strains of bacteria out in the community. These resistant strains are becoming more and more difficult to treat. Many now believe the common practice of treating common colds with antibiotics added to the development of these resistant strains. With evidence based medicine analysis, we now know that 30% of all antibiotic prescriptions may not be necessary. With evidence based medicine, up to date physicians will make recommendations based on the latest scientific data, and not just based on tradition, or trained learning - learned years ago during their residency. Of course, the tension is the anxiousness of the person with the cold, and also the confidence that person has in their doctor. If there is no confidence, usually that person will demand antibiotics, and because it is easier to write that prescription than to take time as a physician to explain why the antibiotic will not likely work. In a small percentage of time, the doctor is in an unfortunate “I told you so” situation where a small percentage of colds do become bacterial infections. For people with neck and back pain, community standards can potentially lead to over utilization of many spine related treatments and activities. Evidence Based Medicine suggests that there has been significant over utilization of tests like x-rays, MRI’s and CAT scans to try to determine the cause of neck and back pain. For the vast majority of neck pain, back pain, and sciatic nerve pain, the episodes usually resolve within 6 to 8 weeks. There are many examples of people getting very expensive, and potentially risky tests and procedures for neck and back pain, but then their pain resolves even before finding out the results of the test. The evidence supports waiting and using common sense approaches like gentle stretches, over the counter medications, and activities modifications while waiting for improvement. As in the example of the cold, it takes time for the Doctor to explain why the testing may not be necessary at the time of the appointment. Sometimes it's just easier to order the test. Also, in certain instances, there are incentives to order those tests. After all, the MRI machines, and the diagnostic facilities do take funds to operate. In my opinion, evidence based medicine has its role, and health care best practices do prevent unnecessary testing or procedures. Still, the role of a specialist is to determine when a person has a situation that falls outside the parameters of these best clinical pathways. In the end, Evidence Based Medicine does provide a good guide for common situations. If you are responding to the Evidence Based Medical protocols, it works out for everyone. If you do not respond accordingly, then the expertise of an experienced Doctor can help you step out of the protocols to help you find your diagnosis or solve your current medical condition. While I'm very supportive of Evidence Based Medicine, I also know the Evidence has changed for many conditions. We all know that the recommendations for eggs, hypertension, things of that nature changed over the years. Yet, we have to go by the evidence. There remains a significant role for Specialist Doctors, even in this Era of Evidence Based Medicine, Artificial Intelligence, and Dr. Google. I am Dr. John Shim, discussing Evidence Based medicine. I hope you found the discussion interesting. Thank you.
Almost daily we read of a new medical study that “proves” yet another food, drink, activity, or medication is a terrible thing or the next answer to all the world’s problems. 20 years ago, eggs were causing an increase in cholesterol and therefore were the main cause of heart disease. 10 years later, eggs were an excellent source of protein and low in calories. Americans now consume an estimated 280 eggs per person per year, according to the U.S. Department of Agriculture.
There is an increasing concern that a portion of medical research studies are either skewed or false. “Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true” says JP Ioannidis who wrote “Why Most Published Research Findings are False”. He feels the smaller the study, the smaller the effects studied, and the prevailing bias, will all make a study less than accurate.
We want to believe.
We want to give our patients good advice, backed by science, and as we all said in our graduation oaths “do no harm”. Decisions are made based on what we have read, our own experience, and what we would advise our own family; but there is always the chance we are wrong. All medical studies are ultimately based on human behavior and we all know how unpredictable that can be. The interference of government, large pharmaceutical companies and even media can also affect many of today’s studies.
Where did the money for the study come from? How many people were involved? How long did it last? Were there adequate guidelines in place? Did they actually prove anything? Are there similar correlating studies? Are the results reproducible? So many questions and so difficult to find the answers, Still, ask them. We are not sheep and should not believe everything we are told.
That said, we need to continue research to improve lives, cure diseases and promote wellness. Let’s just add a little healthy skepticism and a lot more knowledge before we change how we live our lives.
- Fersum KV, Smith A, Kvåle A, Skouen JS, O'Sullivan P. Cognitive Functional Therapy in patients with Non Specific Chronic Low Back Pain A randomized controlled trial 3-year follow up. Eur J Pain. 2019 Apr 11; PubMed PMID: 30974479