When I was in training at Duke University Medical Center, we prided ourselves on practicing evidence-based medicine. During my tenure there, Dr Robert Califf had constructed the clinical research mecca known as the DCRI (Duke Clinical Research Institute). As cardiology fellows in training, we were all actively engaged in clinical trials and quickly understood the importance of choosing therapies that had been proven to be safe and effective through rigorous evaluations in randomized controlled clinical trials. (RCT). In fact, when making rounds in the coronary care unit (CCU) with my attending physician, I can remember being chastised because I had prescribed an ACE inhibitor without mortality data rather than one that had been proven to save lives. In the eyes of my attending, I had wrongly assumed “class effect” and had used an unproven therapy.
This week in the New York Times, author Nicholas Bakalar explores the same issue in today’s medical practice. In a recent publication in the Mayo Clinic Proceedings, investigators evaluated 10 years of published studies in a single high impact journal. Of the studies evaluated, 367 represented an examination of a well established medical practice or therapy. Surprisingly, 147 of these studies of established practices found that the accepted therapy was no better or even worse than the alternative treatment practice. Of these well established treatment practices that were examined, nearly 40% were found to be ineffective or actually harmful to the patient. However, physicians continued to utilize these particular therapies. Why? What can we do to effect changes in practice?
Old habits die hard. Often, in medicine, the momentum it requires to make a change in practice can be overwhelming. We often do things because mechanistically, they just make good sense. Many physicians that are procedure-oriented like myself fall into the trap of believing that if we are able to impact the cause of a problem or change the course of the disease, that the outcomes will be improved. This is not always the case. For example, in the case of coronary artery disease, it makes sense that if we “un-block” an occluded coronary artery, we should be able to make the patient live longer. In fact, the data clearly shows that angioplasty and stenting are valuable in relief of symptoms but have no impact on mortality. This does not necessarily mean that we should not revascularize patients percutaneously BUT it does mean we must understand the true impact our revascularization procedure will have on the patient and their quality of life.
In medical school, most physicians were trained to think as scientists. The scientific method suggests that scientists should evaluate a problem in the following manner: 1. ask a question, 2. make a hypothesis, 3. develop a “test” for the hypothesis and then 4. Collect and interpret the results. As practicing physicians, we must continue to think like scientists and look for evidence to guide our clinical decision making. We must ensure that even if we believe that a particular treatment makes good biologic and mechanistic sense, it must still be proven effective by rigorous clinical trial evaluation–if it is not or if it is shown ineffective, we must find alternative therapies without delay.
Medicine remains an art. The way in which we are trained has a significant impact on how we practice later in our careers. In residency and fellowship, we are taught the current, state of the art therapies for that particular time. Thankfully, medicine is not static–innovations and improvements in care occur almost every day. We must learn to adapt to changes in the “state of the art” as medicine continues to advance. A good scientist (and a good physician) continually evaluates the “state of the art” in order to see if there are better ways to treat and serve our patients. It is essential that we continue to practice evidence based medicine and provide the best PROVEN therapies (and reject those that are found to no longer be effective)–even if it means and “old dog” must learn a “new trick”