William Cayley: EBM—curing and comforting

bill_cayleyrecent article in The BMJ on the crisis in evidence based medicine (EBM) did a great job of both summarizing challenges that have developed over the past 20 years, and proposing some ways forward in delivering better evidence based care to our patients. Unfortunately, I think one piece of the evidence based puzzle is still getting short shrift. We focus on how to provide care with good outcomes to our patients, but do we pay attention to how they feel?

When I teach evidence based medicine, I argue that we need to be looking for the best evidence on outcomes that matter to our patients, and that, fundamentally, those outcomes need to be thought of in terms of either mortality or morbidity. That is, what evidence do we have that will help us determine how to aid our patients in living longer and/or feeling better.

There are lots of surrogate outcomes we can measure as intermediaries (haemoglobin A1c, blood pressure, angiographic size of a lesion, etc), but as we all (hopefully) know, the linkage between surrogate outcomes we can measure, and what will actually help our patients live better or longer, can sometimes be tenuous.

So, I was a bit surprised to find that the word “symptom” appears only once in the otherwise excellent piece by Trisha Greenhalgh and colleagues. Granted, they make the important point that “real” EBM must engage patients in shared decision making over what outcomes to pursue. But it needs to be emphasized that this should not simply focus on patient selection among outcomes that we (the medical profession) deem important (i.e. measurable), such as length of life, cure rates, and the like. Instead, symptom control, pain relief, and how the patient feels must also be taken into account.

To take a somewhat mundane example, I hear it often argued that “evidence” does not support antibiotic treatment for infectious conjunctivitis, because it is a self limiting condition. Nevertheless, the most recent Cochrane review has documented that “the use of antibiotic eye drops is associated with modestly improved rates of clinical and microbiological remission in comparison to the use of placebo.” We doctors may want to argue against antibiotic drops for conjunctivitis as part of the (well justified) effort to limit antibiotic resistance, emphasizing as well the valid point that “you’ll get better on your own anyhow.” Yet evidence based, patient oriented care demands engaging the patient in that discussion as well, since getting over a self limiting condition sooner may well matter to some of our patients.

Granted, this is a rather simple example. Granted, too, that sole focus on symptomatic relief, or patient satisfaction, may lead to an overly consumerist approach to medicine (and the concern has been appropriately raised elsewhere that an inordinate focus on patients’ self reported satisfaction with pain relief may have been a contributor to the epidemic of narcotic overprescription). Granted, finally, that there is much EBM that addresses QALYs and DALYs (though I’ve never had a patient come in to see me and ask, “How can I get a few more QALYs?”).

My point is simply that—as we move forward seeking to improve “conscientious, explicit, and judicious” application of the best, available evidence for the compassionate care of our patients—we need to focus on the hard outcomes of disease treatment and prevention. But we also need to focus on the “soft” outcomes of how our patients feel and how well they live—explained in terms that our patients understand, and to which they can relate. Or, as the aphorism for doctors goes: “To cure sometimes, to relieve often, to comfort always.”

William E Cayley Jr practises at the Augusta Family Medicine Clinic; teaches at the Eau Claire Family Medicine Residency; and is a professor at the University of Wisconsin, Department of Family Medicine.

Competing interests: “I declare that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare beyond a passion for clear and critical thinking.”