A recent article in the Journal of the American Medical Association (JAMA), titled “Continuing Medical Education: Let the Guessing Begin,” examines a potential change in medical and continuing medical education (CME). The author Robert H. Brook, MD, ScD writes that “the purpose of this Commentary is to suggest exploration of a culture shift in medicine to reinforce the notion of knowing the right answer every time.”
He poses the question: “What if the testing process in medical school or CME were changed so that the medical student or physician were faced with a problem and had to decide what to do?” In response to this question, he noted that medical students and physicians would use this type of experience to “how to look up information, read articles, determine if the articles were relevant, and how to apply the literature and evidence-based medicine to individual patients.”
The importance of such experience is necessary because sometimes, “a physician needs to know immediately what to do.” As a result, he acknowledges that a list of medical emergencies and related patient scenarios have already been “developed, as well as a system for reminding all physicians, regardless of specialty, what to do in these situations.” For example, when a patient comes in to complain about “certain types of chest pain, headaches, and other symptoms” physicians are able to refer to these scenarios “100% of the time without looking it up.”
Using this example, the author suggests that such experience and related patient scenarios should be expanded to the rest of medical practice, and to do so, Robert H. Brook, M.D., asserts that “evidence-based medicine must be translated into practice.”
His editorial goes on to talk about his experience with the Medical Knowledge Self-Assessment Program curriculum for internists, and how it lacked “any quantitative decision tools.” Seemingly, although “private firms are beginning to collect decision tools and make them available to physicians … medical decision making has been largely ignored.”
Dr. Brook goes on to discuss his apparent frustration with the fact that “few physicians enter on a patient’s record the probability that the patient will have a cardiac event in the next 10 years.” Additionally, he wanted to understand why there are no formal assessments of probabilities and utilities in making difficult clinical decisions?” In his ideal clinical practice, a patient should enter a physician’s office and the doctor should record “a prior probability that the patient has condition x, y, or z; then, based on the history and physical, produce a posterior probability that serves as the basis for ordering tests.” While such an idea certainly could benefit numerous patients, more research and evidence is needed to back up the effectiveness of such a proposal—but it’s still worth a try. The only problem today is, Congress doesn’t want doctors to order ‘unnecessary tests’ and predict the probability of such conditions because it raises the cost of government run programs such as Medicare and Medicaid.
Consequently, Dr. Brook goes on to further his claim by noting that electronic health records and health information technology are making it easier for doctors to order tests, and over the next 5 to 10 years “a multitude of new tests will come to market to measure specific aspects of a patient’s genetic, proteinic, or physiological nature,” which will ultimately make people healthier. The question remains though: what price is society willing to pay for the kind of decision making and practice so that physicians can “make the right diagnosis, and monitor therapy.”
Ultimately, he asserts that because “physicians are using the same information sciences that were used 30 years ago … it is time for a change, otherwise, innovative medical researchers who develop a new array of tests and measurements” will make it even less likely that physicians will have the right answer.
In order for physicians to start using evidence-based decisions, funding and research is going to be needed to examine the importance of tests, medical devices and new treatments. While the recently released budget does not seem to have money specifically for such decision based research, industry will most likely have the responsibility of bringing evidence-based medicine to patients.
How will the evidence keep up with the new tests and scientific information that will become available especially with the mapping of the human genome and the implications of personalized medicine?
It would seem that to have purely evidence based medicine, a whole new layer of health care will be required.
I’m not saying that is necessarily bad..I’m just suggesting that it may be impossible to interpret all the “evidence” since it may not always exist and it may keep changing…much as we see in science and medicine today. New facts and information emerge on an ongoing basis that change how we manage patients. This is necessary.
However, evidence based medicine will be an expensive moving target. Perhaps something that needs embracing…but lots of cost involved.
No doubt there are some people who say we cannot afford NOT to encourage more evidence based medicine. I agree that evidence based medicine is important but not necessarily achievable across the board at any point in time.
Great Comment, innovation is great, but just like going to the moon, it may take awhile to implement and see the external results (silcon chip, micro computers….)in the end we will live longer. The point of the story is evidenced based medicine is an ever evolving science…..