What Evidence Based Medicine is Not: Part 2
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How would you define wisdom? The Cambridge Dictionary defines wisdom as “the ability to use your knowledge and experience to make good decisions and judgements.” My favorite definition comes from pastor and theologian, Timothy Keller, who defined wisdom as “making good decisions when the rules don’t apply.”
In our last column of Follow The Science, we discussed the common myths of Evidence Based Medicine (EBM). I argued the most common misunderstanding of EBM is the “RCT or bust” fallacy. In other words, many believe that EBM is concerned solely with the results of the randomized controlled trial (RCT) and ignores all other forms of evidence. In addition, I described typical responses to this fallacy as “The Snooty Academic” and the “Blue Collared Clinician”. For more on these descriptions, please go back and read “What Evidence Based Medicine is Not: Part 1.”
How do we, as busy clinicians in the trenches of patient care, appraise and apply EBM to our practice? If you’ve read all that I’ve written so far on this topic, I’m hoping your answer will be to adopt the mindset of “The Wise Practitioner.” As previously discussed, The Wise Practitioner critically appraises the best available evidence and weaves it together with their own experiences to find a solution to match their patient’s preferences. They do not limit their recommendations to only RCT evidence like The Snooty Academic or ignore any RCT results when it contradicts their experiences like The Blue Collared Clinician. They are skillfully academic and practical. How? They assess evidence in degrees of certainty, and they communicate complexity.
Degrees of Certainty (and Uncertainty)
The Wise Practitioner sees evidence through the lens of varying degrees of certainty. Fundamentally, they realize “following the science” doesn’t mean adhering to specific facts but adhering to a process of reducing uncertainty. They know what they know and what they don’t know. The more they learn they realize knowing what they don’t know is more important than knowing what they do know. They see evidence on a continuum of higher degrees of certainty (RCTs) versus low degrees of certainty (single cases and their own biased experiences) and make clinical decisions for their patients often from both ends of the spectrum. They then educate their patients on the level of certainty, so the potential risks and benefits are known.
Communicating Complexity
Wise Practitioners communicate complexity. Contrary to popular belief, communicating complexity increases trust rather than decreases trust.1 This may be controversial, but simplifying the message about a treatment is more of a marketing endeavor than appropriate patient education and informed consent. The Wise Practitioner agrees with this excellent quote from the medical ethicist, Imogen Evans:
“The complexity of discussing therapeutic uncertainty with patients is unnerving some doctors. Some are simply fearful of provoking anxiety – doubtless a genuine concern but nevertheless paternalistic. Others try to justify their actions in terms of a balance between two ethical arguments – whether the ethical duty to tell the truth extends to being explicit about uncertainties versus the moral obligation to protect patients from emotional burden. Are patients prepared to live with uncertainty? We need to find out. Perhaps people are far more resilient than doctors suspect.”2
The Wise Practitioner Applied
How would The Wise Practitioner apply the results of the DREAM (The Dry Eye Assessment and Management Research Group) study on omega-3 fatty acids? I believe The Wise Practitioner would neither disavow omega-3s for patients with dry eye nor ignore the DREAM study results. In other words, as the DREAM study essentially concluded, adding 3 grams of omega-3s to moderate to severe dry eye patients on concurrent forms of treatment is not likely to cause improvements.3 However, what about treatment naive patients? Mild dry eye patients? Patients with elevated levels of MMP-9s? Only more studies and time will increase the certainty of the answers to these questions. For now, The Wise Practitioner would continue to prescribe and communicate the certainty of the evidence inside and outside the bounds of the known clinical trials.
Let’s consider one more example by looking at The Steroids for Corneal Ulcers Trial (SCUT). The SCUT randomized 500 patients with bacterial keratitis to receive either placebo or topical steroids after an initial 48 hours of treatment with topical antibiotics. Results showed no difference in visual acuity at 3 months or safety concerns between the two groups.4 Much has been written on this topic since 2011 so I will spare you a complete review. However, one consideration often overlooked when applying this major study to clinical practice is the baseline characteristics of the study population. A Wise Practitioner asks, “are the patients in this study similar to the patients I regularly see?” Often overlooked within the SCUT trial of 500 patients is 339 were foreign body induced infections, 118 of those were vegetative matter, and only 8 were contact lens related. Is an “n” of 8 enough to inform my use of steroids in my bacterial keratitis patients whom most of them are contact lens wearers? Of course not. Can I still recommend judicious use of topical steroids for my contact lens wearing patients with bacterial keratitis? Yes, but it will take prudent prescribing and consistent follow up with an uncertain outcome.
In both studies, specific prescribing rules are often created out of a simplistic understanding of the results. But closer inspection reveals those results must be applied with nuance and wisdom (there’s that word again). The Wise Clinician uncovers nuance, embraces the uncertainty, communicates the complexity, and applies evidence to practice both academically and practically. When we understand EBM not solely as applying the written rules of RCTs but wisely appraising research evidence and applying it through our clinical experience and our patients’ preferences, we end up truly “following the science.”
References
- Grant, Adam. Think Again: The Power of Knowing What You Don’t Know. New York: Penguin Audio, 2021.
- Evans, Imogen. “More nearly certain.” Journal of the Royal Society of Medicine vol. 98,5 (2005): 195-6.
- Asbell PA, Maguire MG, Pistilli M, Ying GS, Szczotka-Flynn LB, Hardten DR, et al. Dry Eye Assessment and Management Study Research Group. n-3 fatty acid supplementation for treatment of dry eye disease. N Engl J Med 2018;378:1681–90.
- Srinivasan, Muthiah et al. “Corticosteroids for bacterial keratitis: the Steroids for Corneal Ulcers Trial (SCUT).” Archives of ophthalmology (Chicago, Ill.: 1960) vol. 130,2 (2012): 143-50.
Dr. Klute owns and practices at Good Life Eyecare, a multi-location practice in Eastern Nebraska and Western Iowa. He is a fellow of the American Academy of Optometry and is certified by the American Board of Certification in Medical Optometry. He writes and lectures on primary eye care practice management, evidence-based medicine, glaucoma, and dry eye disease.
