People who have been following my writings over the years know that I have been very critical of the concept of “Evidence-Based Medicine”. In fact,in my first book,”Snakes and Ladders“,I made the following provocative statement:”There is no Evidence for Evidence -Based Medicine”.You will have to purchase the book to see the argument laid out there lol. I will not go into the details of this critique in this article but suffice it to say that if one applied this principle whole-heartedly one would become a victim of what my mentor in psychiatry ,Dr. Heinz Lehmann,called “cook-book medicine’ something that is all too common in current medical practice-doctors blindly following algorithms and principles that they heard at the last medical conference they attended or the last peer-reviewed journal article they read.

Let me begin this exposé by saying clearly that I am not recommending that one ignore the evidence. That would be irresponsible.Rather one should include the evidence as one of the factors in one’s decision-making process but only one of them.Remember also that the evidence is invariably statistical so it may not apply to the particular individual case you are treating.

So what are the other factors one needs to consider?This is by no means an exhaustive list but highlights some of the important modalities one should consider:

1) Clinical Experience.What have you seen (we will fashion this teaching as one designed for a medical practitioner-for the sake of clarity only.Patients and their relatives can adjust the formulation to their own needs and vantage points) to date in your clinical practice in similar cases.This assumes, of course, that the medical practitioner is treating each case as a scientific,learning process rather than a process of applying robotically what he learnt theoretically in medical school.” Medicine is an experimental process” I repeated to my own students.Obviously here,the advantage is to those practitioners with more experience-provided they have been able to learn from their own experience! This leads directly to the second modality:

2) Wisdom gained in clinical experience by more senior colleagues.This of course happens on a regular basis in clinical rounds and conferences at hospitals and clinics around the nation.Surprisingly,however, it is rarely included in the pedagogical concepts taught to medical personnel.The evidence-base that is emphasized  almost universally refers to formal research studies.

3) What the patients say and describe! Shocking idea to most medical scientists.The patients experience is relevant-often that is what should predominate rather than the medical literature.How many patients have I heard say:”The doctor wasn’t listening to me”. Of course not! Besides the over-ambitious caseload he is carrying he also has the ideological back-drop of “Evidence-Based Medicine”.What can the ‘subjective comments” of patients be worth in that context?!

Btw I could give clinical examples of each of these modalities but for the sake of brevity I will have to forego those examples for now.

4) Intuition.After all medicine is as much of an art as a science.Needless to say,as far as I know, there is not a single medical school giving a course to doctors on developing their intution.Just like there is not a single course in law school teaching human psychology to lawyers.Reality is indeed stranger than fiction!

5) The “scientifically plausible hypotheses”.This is something I heard only once in all my CME courses but it immediately caught my attention.What it means is that one should go back to basic scientific knowledge like physiology,anatomy,histology and biochemistry in trying to analyze what is really going on.This is one case where I will give a clinical example as the idea might not be clear otherwise.

I am at a passover dinner many years ago at my parents place.One of their friends is coughing intensely.”What’s going on ,George?”I asked.”i have this intense cough and the doctors don’t know what to do about it”.”So what did they propose” I asked.”They said there were studies to show that sometimes the cough is related to hiatus hernia.So they did a four-hour painful operation on me for that! ” Did it help?” .”Not at all” he responded.” I haven’t studied basic sciences in a long time” I mused”But if I remember correctly a cough is a symptom in the respiratory tract”.Did anyone refer you to a Respiratory Disease specialist?” No,not at all” So I did. There was a very good specialty clinic at the time called the Royal Edward Chest Hospital in Montreal.He was assessed there.The doctors concluded that he had asthma! And with asthmatic medications his problem was solved! All a question of basic anatomy!

There may well be other considerations in clinical decision-making like cultural and economic ones but the point here is that you cannot solely rely on the peer-reviewed scientific literature in order to be a competent physician.That would be doing a disservice to your patients and yourselves. Salaams,Joel Ibrahim Kreps