Science-Based Medicine?

“We believe that the vast majority of what physicians do is backed by solid science. Their diagnostic and treatment decisions must reflect the latest and best research. Their clinical judgment must certainly be well beyond any reasonable doubt. To seriously question these assumptions would seem jaundiced and cynical.

But we must question them because these beliefs are based more on faith than on facts for at least three reasons, each of which we will explore in detail in this section. Only a fraction of what physicians do is based on solid evidence from Grade-A randomized, controlled trials; the rest is based instead on weak or no evidence and on subjective judgment. When scientific consensus exists on which clinical practices work effectively, physicians only sporadically follow that evidence correctly.

Medical decision-making itself is fraught with inherent subjectivity, some of it necessary and beneficial to patients, and some of it flawed and potentially dangerous. For these reasons, millions of Americans receive medications and treatments that have no proven clinical benefit, and millions fail to get care that is proven to be effective. Quality and safety suffer, and waste flourishes.

We know, for example, that when a patient goes to his primary-care physician with a very common problem like lower back pain, the physician will deliver the right treatment with real clinical benefit about half of the time. Patients with the same health problem who go to different physicians will get wildly different treatments. Those physicians can’t all be right.

Having limited clinical evidence for their decision-making is not the only gap in physicians’ scientific certainty. Physician judgment—the ‘art’ of medicine—inevitably comes into play, for better or for worse. Even physicians with the most advanced technical skills sometimes fail to achieve the highest quality outcomes for their patients.  That’s when resourcefulness—trying different and potentially better interventions—can bend the quality curve even further.

And, even the most experienced physicians make errors in diagnosing patients because of cognitive biases inherent to human thinking processes. These subjective, ‘nonscientific’ features of physician judgment work in parallel with the relative scarcity of strong scientific backing when physicians make decisions about how to care for their patients.

We could accurately say, ‘Half of what physicians do is wrong,’ or ‘Less than 20 percent of what physicians do has solid research to support it.’ Although these claims sound absurd, they are solidly supported by research that is largely agreed upon by experts. Yet these claims are rarely discussed publicly. It would be political suicide for our public leaders to admit these truths and risk being branded as reactionary or radical.

Most Americans wouldn’t believe them anyway. Dozens of stakeholders are continuously jockeying to promote their vested interests, making it difficult for anyone to summarize a complex and nuanced body of research in a way that cuts through the partisan fog and satisfies everyone’s agendas. That, too, is part of the problem.

The problem is that physicians don’t know what they’re doing. … The plain fact is that many clinical decisions made by physicians appear to be arbitrary, uncertain and variable.”

— Sanjaya Kumar and David B. Nash, Scientific American

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