Good medicine relies on evidence, wisdom
If there exists a dogma within the institution of modern medicine, it is the practice of evidence-based medicine. Generally speaking, evidence-based medicine refers to the application of the best available clinical evidence by providers when making decisions regarding the care of individual patients. Today’s doctors are fortunate to have a bottomless well of data at their fingertips to help patients make medical decisions. However, a dogmatic approach to care that fetishizes data in the face of collective wisdom can be wasteful at best and harmful at worst.
Most often, evidence-based guidelines help doctors make decisions regarding evaluation and management of specific disease processes. It is up to the clinician to put recommendations into the context of the patient sitting in front of them in the exam room.
The holy grail of evidencebased medicine, the randomized controlled trial, unfortunately has many shortcomings. Notably, they are very expensive to perform. This naturally results in the interventions that are most intensely studied happening to be those that have the best chance to be lucrative. This incentive structure can result in recommendations that are counterintuitive to our generally shared values and, as such, further undermine institutional trust.
A recent example is the new recommendations from the American Academy of Pediatrics that obese children as young as 12-13 be considered for injectable weight loss medications and, in some cases, even weight loss surgery. It does not take a physician to understand that, although there may be good evidence that drugs such as Ozempic can stimulate weight loss, it may be unwise to commit youngsters to a lifetime of expensive injectable medicine or the nutritional deficiencies associated with bariatric surgery to solve a problem created by our highly subsidized and exploitative food-production industry.
On a day-to-day basis, the misapplication of evidence takes place in the care of our seniors who often continue to undergo routine screening or receive aggressive treatments for disease far past the time that these interventions could extend life expectancy or improve quality of life. Patients with illnesses such as metastatic cancer or end-stage congestive heart failure are often harmed by aggressive evidencebased solutions such that their quality of life suffers to a degree that most anyone would find unacceptable.
The well-known oncologist Ezekiel Emanuel has famously stated that he will stop preventative screenings and aggressive care for certain diseases at age
75. This may seem nihilistic to some but, as someone who has seen first-hand the diminishing returns offered by aggressive care in our older population, I can certainly relate to this sentiment. The extent of care one receives is a deeply personal choice and patients can advocate for themselves by bringing conversations about their goals of care to the forefront during routine visits with a primary physician.
Of course, medical practitioners must rely on the best available evidence when counseling and treating patients. However, the most skilled medical professionals will be familiar enough with evidence-based guidelines to apply them in the context of the values, goals and resources of their individual patients. Patients with complex medical challenges will be particularly well served by developing a relationship with a primary provider who concerns herself with who they are as individuals and they should steer clear of providers and health care organizations for whom the answer to every medical question is an additional high-tech and expensive intervention.
Seniors, in particular, are vulnerable to unnecessary testing and treatments and should review any recommendations made by third parties with a trusted primary physician before undergoing testing or starting new medications.
Effective stewardship of care within our complex system requires the synthesis of available evidence within the context of the individual patient. A dogmatic approach that overemphasizes statistical outcomes for individual diseases is costly and can have disastrous effects for patients and our community. A trusted family physician can be a well-positioned steward to help patients navigate the labyrinth that is the health care system.