Nothing should be affirmatively promoted unless there is good evidence of at least some benefit. - David Eddy.

Although I have discussed(dissed?) evidence based medicine on multiple occasions, it has previously been a topic reserved for aspiring academics and power hungry quality assurance managers. However, in the name of reform, these groups are trying very hard to bring the issue before the public, purportedly to improve medical care, and maybe sell a few books and get a consulting gigs on the side.

A new article in Scientific American, (which is really an advertisement for their book and consulting company) sets out the case for evidence based medicine, and raises some serious issues about the quality of healthcare in America. The article is long, and the book is longer, and for those seriously trying to understand the issue may be worth reading. For the rest of you I will try to summarize it here

1) There is a high degree of scientific uncertainly in modern medicine

2) Only about 20% of medical therapy is backed by well proven, double blind, randomized studies

3) "Correct" treatment is rendered only 50% of the time

4) Clinical decisions are often arbitrary, with variation between different physicians, and with the same physicians over time

5) Physicians are not necessarily following the evidence that does exist about best treatments

6) Older physicians seem to do worse following guidelines than younger ones

7) Many treatments are performed with limited evidence

8) Back surgery doesn't work particularly well

9) Ask your doctor for evidence the treatment works before you get it

For dedicated readers of my blog, little here is really new. Many of these topics have been covered in part in prior postings. With a few minor exceptions, I cannot argue with any of the contentions made by the authors of the article referenced. What I do contend is that most of what they are saying has little to do with the actual practice of medicine. Science, evidence and best outcomes have something to do with medicine, but are far from the total story. Medical school professors and medical business consultants(the authors of this article), are insulated from the day to day warfare that occurs in the front trenches of giving care. Medical practice is about people as much as about outcomes, satisfying patients, other doctors, and ones' self are at least as important as minimal statistical improvements in population outcomes. Doctor's treat patients, and their demands, individual needs, and other practice concerns frequently make deviations from care standards unavoidable. More to come.