In this era of EBM, it is tempting to think that all the difficult decisions practitioners face have been or soon will be solved and digested into practice guidelines and computerized reminders.
However, EBM provides practitioners with an ideal rather than a finished set of tools with which to manage patients. The significant contribution of EBM has been to promote the development of more powerful and user friendly EBM tools that can be accessed by busy practitioners. This is an enormously important contribution that is slowly changing the way medicine is practiced.
One of the repeated admonitions of EBM pioneers has been to replace reliance on the local “gray-haired expert” (who may be wrong but is rarely in doubt) with a systematic search for and evaluation of the evidence.
But EBM has not eliminated the need for subjective judgments. Each systematic review or clinical practice guideline presents the interpretation of “experts” whose biases remain largely invisible to the review’s consumers.
Moreover, even with such evidence, it is always worth remembering that the response to therapy of the “average” patient represented by the summary clinical trial outcomes may not be what can be expected for the patient sitting in front of a physician in the clinic or hospital.
This is a nice way to say that you better deal with EBM but also you better find a way to treat the individual and not the average or norm. Yes EBM was meant to get rid of the "gray hair" who knows everything from experience. Sometimes they do. The real problem is twofold; the system and the hand off. One is reminded of the 1970 file, The Hospital, with George C Scott, timely for me in 1971, where a large NY city hospital is falling apart. Things have not really changed much, just different protesters and nurses do not wear uniforms and the docs dress worse than the trash handlers, and appear worse.
But as to the above:
1. The system fails all too often on hand off, especially with Medicare patients. They go from hospital to nursing home to hospital. Typical case, MI and goes to hospital, put on 12 meds, goes to nursing home, hypotensive crisis since no one read BP and then back to hospital. Costs, astronomical, patient quality of care, zero, frequency, all the time. There is no follow through.
2. Patients are all different. There are rules of thumb but all too often medicine deals with what and how and the why is too difficult.
Thus the back handed compliment for EBM is well phrased. It is being mandated but it is built with well phrased fatal flaws. In earlier versions of Harrison's they flaws would have been directly articulated. In the post new health care kingdom one must be careful of words.
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