I was reading an article about the controversial Dr. Oz this morning when a quote from a doctor struck a nerve. In reaction to Dr Oz’s embrace of alternative medicine, he stated: “I’m guided by the evidence.” That’s a wonderful and comforting sentiment to any logical person. We have a methodology called science which helps us move towards the truth through a repeated, disciplined process of experimentation. This process allows us to build confidence in our opinions and actions when we have accumulated sufficient evidence or can appeal to previous authority. The problem is that evidence in medicine is rarely imbued with absolute authority, yet the dogma of medicine is that peer-reviewed journal results are the primary guide to treatment. Clinical trials should be viewed as the starting point in the practice of medicine, not the destination.
I’ve been following a great discussion on Susannah Fox’s blog today. The Lohr article that sparked her post and subsequent comments have taken up the position that Evidence Based Medicine tends to dismiss the role of intuition. I think that is true and reflects a cultural phenomenon that seeks a deus ex machina. Fads emerge and advocate for the latest savior (or rainmaker), eschewing the difficulties and hard work involved in engaging with truly complex, multi-factorial systems.
I’m reminded of a music professor who told my composition class that, “you can’t break the rules unless you first understand the rules.” I’ve thought about this for a long time, why is it you can’t be creative in ignorance of the rules? Ignorance of impossibility, after all, is often the fuel for innovation. Yet it seems to hold true that the best musicians don’t run away from convention, they master and move beyond it. Does a powerful command of the grammatical rules and literary traditions of English limit your creativity in writing? No, it hones and unleashes it!
In it’s ideal form, EBM is a foundation of evidence and rules that should empower and propel individual physician and patient creativity. In the quality improvement context the standard of care is there to help us avoid repeating other’s mistakes, not to tell us what to do under all circumstances. The prosaic landscape of diagnostics and therapeutics are governed by probability distributions over endpoint outcomes, but beyond this there remains endless room for innovative thinking and intuition because any time we come into connection with real people and real bodies, we exceed the ability of our formalisms to compute. We can only meet the challenge of other’s humanity through the lens of our own.