Clinical Jazz Harmonizing Clinical Experience and EvidenceBased Medicine

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Clinical JazzHarmonizing Clinical Experience
and Evidence-Based Medicine

• David C. Slawson, MD
• Allen F. Shaughnessy, PharmD
• Lorne A. Becker, MD
• Shaughnessy AF, Slawson DC, Becker L. Clinical
  jazz Harmonizing clinical experience and
  evidence-based medicine. J Fam Pract
  199847425-8.

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Objectives

• Perceived conflicts between EBM and clinical
  experience
• Problems associated with relying solely on
  clinical experience- self/experts
• Restructuring into harmony- clinical jazz

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Wait a Minute! What About Clinical Experience?

• Clinical science and clinical expertise both
  have their essential place in medicine. There is
  potential danger in attempting to replace one by
  the other, in banning intuitive knowledge from
  the realm of the rational and in placing
  explicit, quantitative, calculating technique
  over implicit, intuitive human understanding as
  the ideal for clinical medical knowledge
• Gordon DR. Clinical science and clinical
  expertise changing boundaries between art and
  science in medicine. Lock M, Gordon DR, eds.
  Biomedicine Examined. 1988Boston, Mass Kluwer
  Academic Publishers, 257-95.

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Clinical Experience

• The fertile ground from which ideas and
  hypotheses grow
• Major conflict Experience doesnt jibe with
  research-based evidence

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Clinical Experience

• Not a source of valid POEMs
• Multiple validity problems

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Clinical Experience - Validity

• Latest bad experience bias
• Out of sight, out of mind
• he would have told me if he was having problems
• Nonrandom loss to follow up
• Dissatisfied customers go elsewhere
• Inability to combine outcome data for multiple
  patients

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Clinical Experience - Validity

• Small sample size
• Stacking the deck Biased allocation to
  treatment groups
• Rose-colored glasses Biased assessment of
  outcomes

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Reverse Gullibility

• The story of Semmelweis
• 1847 hand washing decreased obstetric mortality
  from 18 to 1.2
• Virulent attacks lead to asylum commitment
• MDIs vs nebulizers, eye-patches, H. Pylori (Barry
  Marshall), home glucose monitors, others

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Experience A problem of perception
Do you see the Dalmatian in the picture?

• Moral Clinical experience sometimes prevents
  seeing the right picture
• Now that you see it, can you try to not see it?
• Moral Experience can result in ideas that are
  difficult to change

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www.optillusions.com
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Perceptions are difficult to refute

• Why is it so hard to believe that this is not a
  spiral but actually a set of concentric circles?

http//www.michaelbach.de/ot/ang_frazer/index.html
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They really are!
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Clinical Experience

• Not really in competition with EBM

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Combining EBM and Experience Clinical Jazz

• Structure
• plus
• Improvisation

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Clinical Jazz

• Improvisation without structure
• cacophony

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Clinical Jazz

• Structure without Improvisation
• tedium

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Remember The Expert

• Expert in diagnosis and procedures (clinical
  experience)
• Not necessarily expert in therapeutics (EBM)
• Case series LOE 4 at best
• The best expert (YODA) combines experience with
  the evidence Clinical Jazz

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Valid POEMs Provide the Structure
gestational diabetes, bone densiometers, lung
cancer screening
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Advantages of Information Mastery

• A liberating structure
• Stable (little chance of ping-pongs)
• Simple rules (find the valid POEMs)
• Relatively non-restrictive
• There arent that many valid POEMs!

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Clinical Improvisation - Opportunities

• Conditions with no valid POEMs
• e.g. Screening for lung cancer
• Conditions with multiple valid POEMs
• e.g. depression

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Clinical Improvisation - Opportunities

• Patients whose characteristics differ from those
  of patients included in research studies
• Implementation methods for valid POEMs

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Clinical Improvisation - Potential Sources of
Inspiration

• Clinical Experience
• Colleagues Ideas
• Local Experts Consultants
• Standard of Care
• DOEs
• Others

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Clinical Improvisation Not a Solo Activity

• Including the patients perspective
• Working with a clinical team
• Working with consultants
• Working with partners

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If you cant listen, you cant play jazz

• Wynton Marsalis

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Using Clinical Experience to Develop Valid POEMs

• For Individual Patients
• N of 1 clinical trials
• For Groups of Patients
• outcomes-based research

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Need for Outcomes Research in the Community
1000 people in the community
750 will report an injury/illness
250 will seek care
9 admitted
3 referred
1 university admission
White KL, et al. N Engl J Med 1961265885-92
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Valid POEMsOutcomes-Based Research

• Goal Not to replace clinical judgment, but to
  give clinicians more information to base opinions
  and practices.
• Primum non Nocere
• Dualism- distinction between clinical
  experience and patient-oriented research is in
  error

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Circle of Clinical Reasoning
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Flaws in the Circle of Reasoning

• Fallacy of Division What is true of the whole
  must also be true of its parts
• Bell curve of clinical response
• Law of Diminishing Return, the Keflex-Reflex

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Flaws in the Circle of Reasoning

• Fallacy of Hasty Conclusion What is true of the
  parts must also be true of the whole
• Using evidence from clinical experience to
  justify a general approach to all patients,
  without applying the rigors of the scientific
  method, may result in harm

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Why is Medicine Here?

• 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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• Mundus Vult Decipi- The world wishes to be
  deceived
• People would rather be deceived than have the
  truth create anxiety.
• -Caleb Carr, Killing Time

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• The only sure foundations of medicine are an
  intimate knowledge of the human body and
  observations on the effects of medicinal
  substances on that body
• -Thomas Jefferson

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• Americas two greatest gifts to the world are
  jazz and Medline.
• --Richard Smith, BMJ 2001

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The Yin and Yang of Medicine

• Start music
• Rigid enforcement of outcomes-based guidelines
  just as misguided as foregoing results of
  patient-oriented research
• The seeming opposites of medical practice,
  clinical science and clinical experience, are
  inseparable
• Structure with improvisation true art

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The Bottom Line

• We may not have all the right answers, but we
  need to find and verify those that do exist for
  the rest, we need to ask the right questions.

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• If we shadows have offended,
• Think but this, and all is mended,
• That you have but slumbered here,
• While these visions did appear.
• And this weak and idle theme,
• No more yielding but a dream,
• Gentles, do not reprehend.
• If you pardon, we will mend
• . . . . So good(bye) unto you all.
• William Shakespeare- A Midsummer Nights Dream