{"id":36685,"date":"2016-05-17T14:52:33","date_gmt":"2016-05-17T13:52:33","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=36685"},"modified":"2016-05-17T14:52:33","modified_gmt":"2016-05-17T13:52:33","slug":"william-cayley-evidence-based-medicine-are-we-really-there-yet","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2016\/05\/17\/william-cayley-evidence-based-medicine-are-we-really-there-yet\/","title":{"rendered":"William Cayley: Evidence based medicine\u2014are we really there yet?"},"content":{"rendered":"<p><a href=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft wp-image-31912\" src=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg\" alt=\"bill_cayley_2\" width=\"123\" height=\"152\" srcset=\"https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2-243x300.jpg 243w, https:\/\/blogs.bmj.com\/bmj\/files\/2014\/07\/bill_cayley_2.jpg 551w\" sizes=\"auto, (max-width: 123px) 100vw, 123px\" \/><\/a>\u201c<a href=\"http:\/\/www.goodreads.com\/work\/quotes\/1808822-de-l-art-de-persuader\">People almost invariably arrive at their beliefs not on the basis of proof, but on the basis of what they find attractive<\/a>.\u201d Blaise Pascal<\/p>\n<p>Can we make evidence based medicine work if we don\u2019t understand the evidence?<\/p>\n<p>I appreciated this week\u2019s <em>BMJ<\/em>\u00a0<a href=\"http:\/\/www.bmj.com\/content\/353\/bmj.i2452\">analysis piece by Margaret McCartney et al<\/a>, which gave recommendations for ways to make \u201cevidence based medicine work for individual patients\u201d <!--more-->(more specifically, how to make evidence based guidelines work for individuals). And if you\u2019d like a more humorous, and musical, version of the same message, take a look at James McCormack\u2019s recent video:<\/p>\n<p><iframe loading=\"lazy\" title=\"End of Guidelines - a parody of End of the Line\" width=\"640\" height=\"360\" src=\"https:\/\/www.youtube.com\/embed\/DHDnqQ_mCBA?list=PL7f1lk-oMpb-pJoeIKVYHreNKun6ha2Z2\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe><\/p>\n<p>Whether you prefer the written analysis or the musical video, they both make clear the point that there needs to be more emphasis on shared discussion in the application of evidence to individual patient life situations, and much less emphasis on unilaterally directing this or that course of action.<\/p>\n<p>However, when discussing recent, well researched, and \u201cwell evidenced\u201d guidelines, I&#8217;ve been startled to hear people (who I <em>think<\/em> would espouse support of EBM) criticize the guidelines for their conclusions, without engaging in a discussion of their evidence base. Two cases in point: the 2013 American College of Cardiology\/American Heart Association\u00a0<a href=\"http:\/\/circ.ahajournals.org\/content\/early\/2013\/11\/11\/01.cir.0000437738.63853.7a.citation\">guideline on the treatment of blood cholesterol<\/a> and the 2016\u00a0US Preventive Services Task Force\u00a0guideline on <a href=\"http:\/\/www.uspreventiveservicestaskforce.org\/Page\/Document\/UpdateSummaryFinal\/aspirin-to-prevent-cardiovascular-disease-and-cancer?ds=1&amp;s=aspirin\">aspirin use to prevent cardiovascular disease and colorectal cancer<\/a>.<\/p>\n<p>Both guidelines have good evidence reviews, and both have (I think) appropriate discussions of shared decisions. They may not be perfect, but they seem to be about the best we can get to, given the fact that all knowledge is limited, clinical science is ever evolving, and we simply cannot find clear answers to all clinical questions. Nevertheless, I\u2019ve been startled to run into more than a few clinicians who take issue with these guidelines\u2019 conclusions, without engaging\u00a0in\u00a0a discussion of the evidence.<\/p>\n<p>In Mortimer Adler\u2019s classic <a href=\"https:\/\/www.goodreads.com\/work\/quotes\/1633521-how-to-read-a-book-the-art-of-getting-a-liberal-education\"><em>How to Read a Book<\/em><\/a>, he argues that \u201cTo disagree without understanding is impudent.\u201d While I\u2019m not sure I\u2019d choose the word \u201cimpudent\u201d in my discussion of evidence based medicine, Adler makes a salient point. To disagree with conclusions, without engaging with the underlying reasoning, is taking an invalid intellectual shortcut.<\/p>\n<p>Granted, evidence based medicine is a complex and ever evolving approach to understanding medical knowledge. Granted, there are manifold problems with evidence based medicine as an intellectual enterprise (evidence that is important but unpublished, \u201chijacking\u201d of the term \u201cevidence\u201d for all sorts of information that isn\u2019t really evidence, problems with trial reporting, etc).<\/p>\n<p>Nevertheless, if we are to espouse (and teach and practice) truly evidence based medicine, our discussions with each other and with our patients need to be first and foremost about the evidence, and then secondarily about the policies and recommendations.<\/p>\n<p>Whether with a colleague or a patient, to leap directly to recommendations without engaging with the evidence constitutes an intellectual shortcut that betrays the first principles of evidence based medicine.<\/p>\n<p><em><strong>William E Cayley Jr<\/strong>\u00a0practices\u00a0at 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.<\/em><\/p>\n<p><strong>Competing interests:<\/strong> I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>\u201cPeople almost invariably arrive at their beliefs not on the basis of proof, but on the basis of what they find attractive.\u201d Blaise Pascal Can we make evidence based medicine [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/bmj\/2016\/05\/17\/william-cayley-evidence-based-medicine-are-we-really-there-yet\/\">More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1357,14769],"tags":[],"class_list":["post-36685","post","type-post","status-publish","format-standard","hentry","category-us-health-care","category-william-cayley"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>William Cayley: Evidence based medicine\u2014are we really there yet? 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