Are Doctors Just Playing Hunches?

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Unfortunately, several years later, the patient was found to have a very aggressive and incurable prostate cancer. He sued Merenstein for not ordering a PSA test, and a jury agreed--despite the lack of evidence that it would have made a difference. Most doctors in the plaintiff's state, the lawyers showed, would have ignored the debate and simply ordered the test. Although Merenstein was found not liable, the residency program that trained him in evidence-based practice was--to the tune of $1 million.

Even champions of evidence-based practice acknowledge that the approach has limits. "Some things can't be tested in randomized trials, and some things are so obvious, they don't need it," says Dr. Paul Glasziou, director of the Center for Evidence-Based Medicine in Oxford, England. There have never been randomized trials to show that giving electrical shocks to a heart that has stopped beating saves more lives than doing nothing, for example. Similarly, giving antibiotics to treat pneumonia has never been rigorously tested from a scientific point of view. It's clear to everyone, however, that if you want to survive a bout of bacterial pneumonia, antibiotics are your best bet, and nobody would want to go into cardiac arrest without a crash cart handy. "Where randomized trials are most important is where you're trying to affect a long-term condition, like stroke or cancer," Glasziou says.

Finally, the very definition of evidence-based medicine is something of a moving target. Physicians who encouraged their female patients to take hormone-replacement therapy to prevent heart problems later on were practicing a kind of evidence-based medicine, since the best available evidence at the time--observational studies and the like--suggested a benefit. Of course, when a randomized controlled trial showed otherwise, the advice changed. Even at that, the case is not entirely closed. Some researchers now believe there may be a window of opportunity right around the years of menopause during which hormone-replacement therapy could help the heart. Proving that would, naturally, require another study.

All the same, few people deny that the trend in medicine is increasingly to be guided, if not governed, by the data--an idea that is spreading to other fields as well. Evidence-based practice is now being taught in nursing, general education and even philanthropy, thanks to the influence of the Bill and Melinda Gates Foundation, a results-based group if ever there was one. You could see even the political fights over global warming as the birth pangs of the new practice of evidence-based policy.

But it is in medicine that the practice will have the most emotional impact. All patients would probably benefit if their doctors were abreast of the latest data, but none would benefit from being reduced to one of those statistical points. "You have to be able to take a good history and do a physical examination," Guyatt says. "And you have to have an understanding of patients' values and preferences." As much as some physicians might wish it otherwise, there is still as much art to medicine as there is science.

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