If the doctor is probably right but my gut instinct tells me otherwise.
The argument for evidence-based medicine has been growing since the start of the 1990s. Evidence-based medicine demands strict adherence to scientific fact and agreed guidelines. At the same time, a different movement has gathered pace: the Patient Expert (personal goals and aspirations) and shared decision making. How do these trends go together? And does one preclude the other?
Evidence-based medicine
Evidence-based medicine focuses on the conscientious, explicit and judicious use of the best current external scientific evidence when making decisions about patient care.
Traditionally, clinical decisions were based on what clinicians learnt while studying and training, as well as on their own professional experience. As a result, different approaches were frequently taken to the same disease, depending on who was treating it, often with very different outcomes.
Moreover, some advice was based on untested hypotheses. For instance, in 1954, the paediatrician Benjamin Spock wrote a book which sold 50 million copies and was translated into 39 languages. In it, he recommended that babies should sleep on their stomachs. He said that, were they to vomit during the night, this would stop them from inhaling or choking on the vomit. In-depth research conducted in the 1970s demonstrated that this recommendation was incorrect and had actually led to the deaths of around 50,000 babies.
This therefore intensified the calls to base clinical decision making on current scientific research (‘evidence’).
Today, evidence encompasses the findings from rigorously conducted clinical trials, therapy guidelines developed by expert bodies or professional medical associations , the recommendations of recognised healthcare organisations , and many other sources.
Today, evidence encompasses the findings from rigorously conducted clinical trials, therapy guidelines developed by expert bodies II or professional medical associations III, the recommendations of recognised healthcare organisations IV, and many other sources.
The Expert Patient
Emerging at around the same time, the Expert Patient approach demands that clinical decision making must be based on the individual views, experiences, preferences and goals of patients. (See the article on the underestimated potential of the expert patient in the ‘Knowledge’ tab on our website).
To give just one example, people assess the risks of side effects quite differently. A particular therapy may be welcomed by one individual despite the side effects, yet those same side effects may make it seem completely unacceptable to another.
A dilemma thus arises in this context. Can patients expect interventions from their doctor that are in line with the patient’s individual views, experiences and goals, but which are not consistent with the scientific evidence?
The limitations of evidence
Evidence-based decisions are of course important and are generally accurate. However, for the following reasons, it is vital to remember that scientific evidence may be relative.
- Evidence is often expressed in terms of probability – for example: “40% of patients experience the serious side effect X”. However, to a specific individual, this information will have only limited value.
- There are a great many medical issues for which no evidence is available.
- Evidence reflects current scientific knowledge. Existing knowledge is constantly challenged by the latest findings. New clinical trials conducted with larger numbers of patients reach a different conclusion to the initial, earlier tests. Guidelines are changed or extended in light of more recent experience.
One does not preclude the otherv
To resolve the dilemma above, the following steps can be taken:
As a patient, ask your doctor the extent to which their recommendation reflects the available scientific evidence.
If necessary, examine the scientific evidence yourself. While the results of clinical trials or the guidelines from expert bodies are often written using specialist language which may be incomprehensible to laypeople, you can ask your doctor to summarise the content of these publications for you in plain language.
Compare the scientific evidence on the one hand with your individual views, experiences, preferences and goals on the other.
If there is a discrepancy, carefully weigh up the pros and cons of the various options with your doctor.
Try to agree on interventions with which both you and your doctor feel comfortable.
If you and your doctor cannot reach a consensus, consider seeking a second opinion.
Further topics
- The Expert Patient
- Structuring doctor-patient consultations
- Dealing with emotions in doctor-patient consultations
Sources
I Evidence Based Medicine and Shared Decision Making: The Challenge of getting both evidence and preferences into health care; Alexandra Barratt; Patient Education and Counseling, 73 (2008) 407-412
II See Cochrane Swiss
III See the guidelines on the online platform of the FMH (the Swiss Medical Association) “Guidelines Schweiz”
IV See the Medical-ethical Guidelines of the Swiss Academy of Medical Science (SAMW) or the recommendations from the movement “Choosing wisely”
V Integrating Patient Values into Evidence-Based Practice: Effective Communication for Shared Decision-Making; Vranceanu, A.-M. et al; Hand Clin 25 (2009) 83-96
Bringing shared decision making and evidence-based practice together; Tammy Hoffmann and Paul Glasziou; in: Share Decision Making in Health Care – Achieving evidence-based patient choice; Oxford University Press, Third Edition, 2016