Bumps in the Road to IMEBHC

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Bumps in the Road to IM/EBHC
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What is Evidence-Based Medicine?

• An acknowledgment that there is a hierarchy of
  evidence and that conclusions related to evidence
  from controlled experiments are accorded greater
  credibility than conclusion grounded in other
  sorts of evidence.
• -- Brian Hurwitz. BMJ 20043291024-8.
• Whats so hard about that?

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Bumps in the road

• Financial disincentives
• Organizational constraints
• Perception of liability
• Patient expectations
• Standards of practice
• Opinion leaders

• Medical training
• Drug companies
• Uncertainty
• Competence
• Need to do something
• Information overload

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Barriers and solutions

• Why are some people resistant?
• How can we bend them to our will?

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Barrier Difficulty finding the evidence

• Too hard to round up all of the information
• Satisficing -- acceptability of an answer,
  not necessarily the answer
• Its impossible to keep up

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Solutions

• Use a clinical awareness system for handling
  your information needs
• Keeping up (foraging)
• Daily InfoPOEMs, ACP Journal Club
• Answering questions (hunting)
• Clinical Evidence
• Essential Evidence Plus
• Best Evidence/ The Cochrane Library

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Barrier Those results dont apply

• All studies are flawed
• All patients are different
• You can find a paper to support anything

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Solution

• All studies have flaws,
  but not all flaws are fatal
• Truth is a probability
• All patients are different, but the goal of
  medicine is to try whats most likely to work
  most of the time

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Barrier Tradition

• From the apprenticeship system of medicine
• The seven deadly words
• Weve never done it that way before
• Weve always used evidence

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Solutions

• Evidence in the traditional sense does not
  equal Outcomes (DOE vs POEM)
• Introduce a culture of questioning and continual
  change
• Make change easier by changing processes

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Barrier Perceived loss of Autonomy

• Guidelines are cookbook medicine
• Anyone can practice medicine with EBM
• computers can see patients

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Solutions

• Good cooks know the recipes and spice to taste
• Clinical freedom implies doing whats best, not
  doing whatever one pleases
• EBM provides the best information for one to form
  the best decisions it doesnt provide the
  decisions themselves

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Barrier It scoffs at Clinical Experience

• If its not from a clinical trial, its not valid
• Ignores the art of medicine
• How do I know it works? I know because Im older
  than dirt . . .

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Solution

• Goals of medicine Relieve/prevent suffering
  maintain/provide hope prevent, treat, or cure
  disease
• The science of medicine knowing the best way to
  prevent, treat, or cure disease (EBM can address
  this aspect)
• The art of medicine Determining, using
  intuition, experience, and judgment, what
  patients need the most
• Clinical jazz science art

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Barrier Statistics scare me

• Too many numbers in EBM
• Medicine is about people, not statistics
• No patient is a likelihood ratio
• Photonumerophobia The fear that ones fear of
  statistics will come to light (D. Sackett)

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Solutions

• Medicine is all about likelihood and
  probabilities
• EBM attaches numbers to highly likely, cannot
  be ruled out, unusual, and other words used to
  describe probabilities

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Barrier Saying Mass in English

• If everyone can have access to the liturgy,
  (the knowledge of medicine) what is the role of
  the priests (teachers)?

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Solutions

• The Priests still have to
• Interpret the medical literature
• Teach the art of medicine
• Teach how to think (vs. what to know)

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Barrier Me vs. Them

• Someone is always trying to change me
• Studies are done out there, which is different
  from in here

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Solution

• For most doctors, change is virtually a routine
  part of life . . . The alternative to controlling
  the process of change is to be controlled by it,
  and in dramatic cases, to experience professional
  or personal collapse.
• One of the greatest pains to human nature is the
  pain of a new idea.

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Sales/Marketing

• Three types of people you will encounter
• Customers- those who are interested in your
  product
• Visitors- those who are there because someone
  told them they should, but they are uncertain
• Complainers- those who are there to thwart your
  efforts

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Sales/Marketing

• Use your time and effort working with your
  customers and enlightening the visitors
• Dont waste valuable energy on complainers,
  despite feeling the urge to do so
• Some early adversaries can become your greatest
  allies

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Suggestions/Solutions/Pearls

• Start a journal club but dont call it that
• Is it true? rounds
• Information Mastery
• Hagy rounds (after chair, to gain his/her
  support)
• Chair commitment to teach curriculum
• Time for teaching and planning
• Watch out for submarine attacks from threatened
  faculty or other clinicians
• EBM is good, but out in the trenches . . .
• Ive practiced all my life without EBM . . .

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Suggestions/Solutions/Pearls

• Work on assimilating outside faculty
• CME evaluation form
• Look for external support/endorsement/funding
• Dean
• Managed care organizations
• Support Group/ Networking