Evidence and clinical judgment should complement each other

The term evidence based medicine provokes strong feelings from its proponents and its skeptics.  I spent a full day recently in discussions about EBM.  As the day proceeded I understood that evidence is wonderful when it fits the clinical question, but that too often the clinical question does not, and probably will not have adequate evidence. We have great evidence for some clinical questions.  We all know that ACE inhibitors decrease mortality in patients having systolic dysfunction.  We know that antibiotics help a variety of documented infections.  We know which biologically active DMARDs improve the course of rheumatoid arthritis.  We know that home oxygen decreases mortality in chronic hypoxic patients. But how many clinical questions lack such specificity.  My recent clinical passion – the Lemierre syndrome – has no evidence for prevention or treatment.  Yet we must make decisions about empiric antibiotics for severe sore throats in adolescents and young adults, and we must choose antibiotics in a patient diagnosed with the syndrome.  We do not have, and likely will not have an RCTs to guide our management.  Rather we must use clinical judgment. Believing in EBM does not and should not eschew faith in clinical judgment.  Many clinical situations do require judgment. Even if one believes in EBM, controversies among guidelines must give one pause.  These likely occur because differing guideline committees have differing priorities and values.  Da...
Source: DB's Medical Rants - Category: Internal Medicine Authors: Tags: Medical Rants Source Type: blogs