So some of my colleagues won't do anything unless there is robust literature to support it. Some will consider doing something if the evidence is there and of decent quality. I'm more of a voodoo person. My basic thoughts are that just because evidence doesn't exist to support something, doesn't mean that it doesn't work. And if the the physiology makes sense, and the risks/costs are minimal to none, there's no harm in trying (especially when there is potential for high reward).
I understand the potential for deluding ourselves into thinking something works, and setting a standard of care, when it doesn't actually work. But sometimes a little voodoo does the trick.
For most clinical decisions, there is no specific level 1 evidence you can look at, that exactly matches your patient population, and the specific clinical question involved, not to mention the real world intangibles, such as psychosocial, practical and administrative pressures. Anyone who thinks they're practicing "100% EBM" is kidding themselves. To even make "100% EMB" based practice as your goal, is not even a good goal, in my opinion. Good quality EBM should be used as a guide, but EMB as a whole misses such a large and growing set of factors that come to play in our work settings, it's ridiculous.
How many double blind, placebo controlled randomized trials, take into account these things, all of which affect decision making?
-"Choosing wisely" cost pressure.
-Administrative pressure over metrics.
-Pressure to cave to demands of instant gratification by patients and run up patient satisfaction scores that ignore best practices.
-Psychotic, violent or intoxicated patients threatening you when you're trying to make your decision based on studies done in a controlled, academic trial setting.
-Patients you see that would have been disqualified from any study based on inclusion criteria which set up a false representation of the "real world."
-Insurance company pressures (certain studies not being paid for, certain meds not being paid for).
-Fear of prescribing/not prescribing opiates due to threat of regulation/lawsuit/board action.
-Fear of false and frivolous malpractice allegations.
-The loss of time that would otherwise have been spent on quality decision making, spent on endless documentation to satisfy pointless, government imposed regulation created by bureaucrats that don't take care of patients (MIPS, MACRA, Meaninless Use, PQRS, VBM, EHRs, Joint Commision, etc)
-The fact that 5% of clinical trials are mathematically guaranteed to be wrong (by the definition of p values & statistics) at a minimum, when perfectly done, and before taking into account bias which can raise the number dramatically higher. Have you ever seen a news report breaking about some new "groundbreaking" study, that said in the article, "Studies like this are guaranteed to be wrong 5% of the time, by statistical chance?" I bet not. Yet the pressure to march in lock-step with the latest and hottest study and it's opinion driven conclusions, remains.
-Other factors
Once you strip away what's left, I'm not so sure how much EBM Perfect-World even helps us, in Medicine Real-World as it exists today. It's a guide and shouldn't be ignored or abandoned totally, but you sure as hell better realize it's limitations if you want to succeed in this Medicine game.
