Monday, November 11, 2013

Evidence Based Medicine

Healthcare Leadership Forum Examines Implementation of Evidence-Based Medicine in Daily clinical Practice.
October 29, 2013 – Philadelphia

Evidence based medicine (EBM) is a common catch phrase used by physicians when discussing patient procedures and outcomes. What does it mean and how is it currently used by your doctor? EBM evolved from clinical epidemiology in the 1980s. In 1996, David Sackett, MD, wrote that “evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” This definition has since been adopted by major health organizations.

Evidence-based decision making certainly has a place in clinical practice. However, it is only one side of a triangle that forms the cornerstone that drives daily practice decision making. The second aspect is clinical experience and the third, and in my opinion, most important is patient preference. Unfortunately, these last two factors are often ignored or even belittled in consultation with health care providers.

Since the use of the term EBM became widespread, I find physicians using it as a blockade to avoid entertaining alternative therapies. The term for this behavior is hypocognition (the absence of a simple, consolidated mental framework that new information can be placed into). Vitamin D is a classic example. Several years ago a well constructed, double-blind, placebo controlled study was performed using a once a week dose of 50,000IU of vitamin D. The study showed good benefits from vitamin D supplementation and has become the “gold standard” for prescribing vitamin D. Every week in my practice, I see patients taking this massive overdose of 50,000IU of vitamin D, once per week, prescribed by their physician. They come to me with multiple joint pain, muscle pain, and muscle spasm. If this practice is questioned, the immediate response is “that’s evidence-based medicine” because that’s what was done on the study. The physician never asks why the study was constructed is this manner or if this protocol is safe or effective for the patient, because it’s EBM and is now the standard of practice.

In truth, the massive, once-a-week dose was done for the sole purpose of making it possible to actually monitor the test subject to ensure that they swallowed the pill. Daily doses of a more reasonable, safer, better utilized vitamin D supplement just were not practical for study purposes. The Nutrition Board recommends doses up to 4,000IU per day without laboratory testing and confirmation of serum levels of vitamin D to recommend daily dosing above 4000IU. That is a simple framework to incorporate the knowledge gleaned from this landmark study.

Your preference as a patient is a least as important as the evidence-based recommendation by your physician. Stand your ground and ask them to relate their recommendation to their clinical experience and your specific situation. If they can not do both, then seek another opinion.