Patients should unambiguously be at the center of our care. This is not up for debate and is hopefully not a controversial idea. Troublingly, I continue to observe the manufacturing of a false dichotomy in which embracing evidence based practice and science somehow must come at the expense of patient centeredness. Ensuring that we are using the most effective and plausible interventions is fundamentally patient centered, because it is the patients who benefit. A strong foundation in science and research is what enables us to best provide quality care.
Health care is predicated on delivering high quality, safe and effective treatment to meet the needs of patients. Evidence based practice was developed because for a very long time, we failed miserably at this goal. As A.B. and I.D. Hill write — “The history of medicine shows many examples of forms of treatment widely considered as effective on grounds of clinical impression which have turned out to be ineffective or even harmful” and as Jeremy Howick details in his book “Some medical historians have suggested that until at least 1860, and probably 1940, most medical interventions were no better than placebo or positively harmful” — This is because treatments were often justified on (mostly incorrect) beliefs about physiological mechanisms and clinical observation, which is a decidedly poor source of knowledge for what works.
One of the most striking examples of this comes from the 1980s — the prescription of a particular class of antiarrhythmic drugs to people after heart attack. Patients after heart attacks often have mild arrhythmias and are at increased risk for sudden death as a result. Antiarrhythmics address these abnormal heart rhythms and in turn were thought to reduce the risk for premature death. This practice was simple and intuitive because of the mechanistic reasoning and clinical expertise involved. It also turned out to be completely wrong and incredibly harmful. The Cardiac Arrhythmia Suppression Trial (CAST) later showed, horrifyingly, that you were actually MORE likely to die when given an anti-arrhythmic drug after your heart attack. It is now estimated that this prescription practice likely caused the premature death of around one hundred thousand people. The reason we do healthcare research is very human — to provide safer treatments and better healthcare to patients.
To be clear, this is not an argument against the need for clinical experience and development of clinical expertise. But, as has been discussed ad nauseum, clinical experience and expertise are not best equipped to determine efficacy and effectiveness. More rigorous testing and investigation is necessary to understand more clearly what works, why it works, how well it works, at what risk and at what cost. This does not mean that clinical expertise is not an integral part of evidence based practice, but its vital role is elsewhere. This is also not to discount patient values and circumstances, because they will ultimately determine what treatments you proceed with. You see, there is an apparent misconception as to what true evidence based practice is. To clarify, Sackett defined it as
the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research
When treating patients, you must use best available evidence, clinical expertise and individual patient circumstances or values to inform your decision making. You do not pick and choose one or two of them, they are not legs of a stool or pillars. Without the whole package, there is no evidence based practice. One aspect of evidence based practice, say best available evidence, does not come at the expense of another, but instead they are meant to coalesce into a singular model. At present, evidence based practice is the best tool we have to deliver high quality care to patients — this should not be a controversial statement.
What is it that provides the best estimate that a treatment is going to benefit the patient in front of you? Systematic research. This does not mean you blindly apply the results of research to the patient, ignoring their values or circumstances and disregarding your developed expertise. It also does not mean that you are unable to use a treatment without robust systematic reviews and meta analyses having already been performed. It means that you use your clinical expertise to assess the patient, critique the best available evidence (which sometimes is simply basic science in physiology, or a case study or maybe even your clinical expertise and past experiences), consider the generalizability of the evidence to the individual in front of you and then provide your expert opinion on best available treatment options. It is our duty as healthcare providers to offer and educate them on the best available treatments, not only to inform and engage patients, but to help them achieve their goals. You then work together with the patient to decide which reasonable and plausible treatment option is going to best meet their needs. If you are not doing this, you are not conducting yourself in a manner consistent with evidence based practice.
Sometimes this means the patient makes an informed decision to not pursue the most effective treatment option. Sometimes their goals might align better with the second or third most effective treatment option, or maybe the best option is actually no treatment at all. But, this is not necessarily a license to perform any intervention the patient requests, desires, or believes to be beneficial. You would not re-align someone’s chakra to address their hypertension because the patient believed in it or perform reiki for someone's neck pain because it "worked in the past" and still be able to reasonably call it health care. Ineffective treatments are useless and the fact that we even discuss how, if, and when we should use them reflects poorly on us as professionals. The topic of addressing patient's beliefs about ineffective or useless treatments is a nuanced one deserving a post all its own, but in brief — it would be hard to go wrong with treating your patient like a human being by having an honest discussion with them about why re-aligning their chakra might not actually lower their blood pressure, assuming you communicate in a way that engages them and involves mutual respect, empathy and patience.
Certainly the execution of evidence based practice can be lackluster (and has been in many respects), but that is a failure of us as clinicians, researchers, regulators, policy makers and payors — not necessarily of evidence based practice itself. The best part of evidence based practice and science is that it is self correcting. If you want good examples of critiques of evidence based practice with actionable solutions, look no further than the work of folks like Trisha Greenhalgh, Ben Goldacre, John Ioannidis, Roger Kerry, Sean Collins, Cause Health, the Critical Physiotherapy Network, and Science Based Medicine among many others. These are examples of science and philosophy in action.
Tweeting about evidence based police taking away from patient centeredness when someone criticizes a poorly supported treatment is the opposite of this. It is not an issue of evidence based practice OR patient centeredness. Just because your modality du jour is not supported by science and the negative published evidence contradicts your observed clinical outcomes with patients does not mean that evidence is nonsense and an emphasis on it comes at the expense of patient's wellbeing. It means that your patients are likely getting better for some reason not unique to your favorite modality. As a clinician, you are obligated to understand the WHY behind what is happening with your care. Sticking your head in the sand with regards to adopting true evidence based practice and adapting to changing information can be argued (rather easily, I would say) to be significantly more detrimental to overall patient care than any hypothetical over-emphasis on evidence.
To say that we focus too much on evidence at the expense of the patient — this makes no sense to me. Jeff Moore recently posed a similar statement on twitter
I'm honestly uncertain which is more detrimental to patient care: an obsession with current best evidence or an absolute disregard for it
To be frank, it should not even be a question. In some hypothetical world where both situations are taken to extremes, it is unambiguous that an absolute disregard for evidence would cause far more harm to patients than an over-emphasis on it. Look no further at how folks fared in the early days of medicine when blood letting was used to balance humors. Take a look at examples of medical reversal in healthcare or the anti arrhythmic drug example mentioned above -- imagine if we ignored the evidence on these things? It would be absolutely disastrous for patients.
Now even in reality, our profession (and healthcare in general) has an unambiguous problem with adopting evidence based guidelines and translating research to practice, not the opposite. It is not the clinicians who suffer because of this, it is our patients who are deprived of best practice and standards of care. To flippantly disregard evidence that contradicts our beliefs and expertise on “what works” or to not perform due diligence in staying up to date with evidence is to squander the best tool we have of knowing what will actually help the patient. We are supposed to adapt and change with new and better information, discarding some treatments and adopting others — this is the foundation of science.
I would wager that most people do not seek healthcare because they already know for certain what is wrong with them and know absolutely what to do about it. Rather, patients seek care because they know doctors, or physical therapists, or psychologists are the experts in their particular field and will use that expertise to work with them to provide the best treatment options to address their present condition. We have a duty to communicate our expertise and best existing evidence in a way that allows patients to make informed decisions. What choice would you make if a provider honestly and patiently explained: “you know what, this Kitchen Sink Therapy may feel good or have appeared to help you in the past, but honestly we now know it does not really do much. For your particular condition and situation there are far better supported and understood treatments that are more worthy of your time and your money. Let me tell you a little bit more about them so you can think about which might best meet your needs.” That foundational approach seems quite patient centered to me and is central to what evidence based practice actually is.