Are Doctors Just Playing Hunches?

Nobody pretends medicine is easy, but if there's one thing we ought to be able to rely on, it's that the doctors looking out for us are doing more than playing hunches. We take certain medicines because they work, right? We go into the operating room for certain procedures because they'll make us well, don't we?

Well, maybe. More and more, however, doctors are making the unnerving case that no matter how reliable a drug or other treatment appears to be, too often there's simply little hard evidence that it would make a long-term difference in a person's quality of life or prolonged survival. Obviously, drugs are tested rigorously to show that they are safe and effective before they are approved by the U.S. and other developed countries. But a clinical study is not the real world, and just because a drug leads to a statistically significant improvement in, say, cholesterol levels doesn't guarantee that the desired effect--a healthier heart and a longer life--will follow. Often your doctor is left to make prescription decisions based at least in part on faith, bias or even an educated guess. That ought to be enough to spook even the least jumpy patient, but the fact is, recognizing just what a roll of the dice medicine can be may be a good thing.

Increasingly, doctors seeking to provide their patients with the best possible care are exploring what is known as evidence-based medicine--a hard, cold, empirical look at what works, what doesn't and how to distinguish between the two. It's not enough to prove that a particular blood test or CT scan really spots cancer, for example. You also need to know whether early detection of that cancer would make a difference in your ability to respond to treatment or it merely means that you would die at the same point but learn about your illness earlier than you would have without the test.

Evidence-based medicine, which uses volumes of studies and show-me skepticism to answer such questions, is now being taught--with varying degrees of success--at every medical school in North America. It has been extraordinarily successful in shooting down some of the most cherished beliefs in health care, like the idea that long-term hormone-replacement therapy would help prevent heart disease in women. And it has clearly saved lives. Many doctors used to give anti-arrhythmia drugs to everyone who experienced irregular heartbeats after a heart attack because severely irregular beats could rapidly prove fatal. But then came the results of a randomized trial showing that patients with only mildly irregular heartbeats were more likely to die if given the anti-arrhythmia medication than their untreated counterparts were. Doctors now prescribe more judiciously, though treatment still saves lives in the case of severe arrhythmias.

Advocates believe that evidence-based medicine can go much further, reducing the reliance on expert opinion and overturning the flawed assumptions and even financial incentives that underlie many decisions. "This is a whole way of looking at the world," says Dr. Gordon Guyatt of McMaster University in Hamilton, Ont., who coined the term and is a pioneer of the evidence-based movement.

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