I recently blogged an ideal description of evidence based medicine. I gave examples to point out that it’s onerous, and I implicitly questioned whether it’s realistic. Truth be told I wonder if many doctors even practice it. A commenter did a better job of making the point. “My goodness. If my physician went to all that trouble for me, I'd require resuscitation from the shock. But to tell you the truth, such extreme conscientiousness -- while I applaud it -- is not only impractical in terms of time (yours!) but also overestimates by a long shot what most patients would expect in terms of empowerment.” (Go read the comment in its entirety).
EBM is indeed rigorous. Formulating a question, translating the question into a search strategy, performing the search and critically appraising what you retrieve is a substantial chore even with the help of the short cuts provided by some medical Internet resources. Of course, your job isn’t finished there. You then must evaluate how well the patient populations represented in the evidence you’ve retrieved match the unique characteristics of your patient and, finally, integrate this evidence with your patient’s preferences, circumstances and values.
Most of us would say we practice EBM but the reality is we often practice only the trappings of EBM. That is, we can quote from randomized controlled trials and talk about meta-analyses, odds ratios and confidence intervals. We can name off a number of things doctors who practice EBM are supposed to do, and to a variable degree, do them. We use Internet resources but often not in a systematic way. With good intentions we put on these appearances and often still don’t really practice EBM as we’re supposed to.
What we have then is a degree of disconnect between the theory and the practice of a revolutionary idea in medicine. This is not unprecedented. It is analogous to another revolution in medical thinking that occurred in the 1960s: the problem oriented medical record, a.k.a. the Weed system. It was the talk of the wards when I was a medical student. Since those days SOAP formatted progress notes have become commonplace, and most medical records have had a problem list, after a fashion. However, this is a far cry from the true practice of the Weed system as it was originally defined and taught. Again, we practiced only the trappings. (In researching for this post I was unable to find any of the original descriptions of the Weed system to provide as links. The articles are old and only the citations are on line. I was able to find a print description in an old copy of Hurst’s The Heart, sixth ed., which contains a description on p. 105. J. Willis Hurst, professor and chairman of the Department of Medicine at Emory, was a champion for the Weed system  . Older editions of his text contain elegant descriptions of the problem oriented medical record as applied to clinical practice, which time and space constraints do not permit me to abstract here).
We miss the mark with EBM, in part because we lack time. Reimbursement incentives put doctors under pressure to see large numbers of patients in limited time, and consequently don’t reward the practice of EBM. How then should we regard it? We should embrace it. If the ideal is unattainable it should challenge, not discourage us. It is a challenge I find fascinating, and one that I approach with the hope that as we ascend the learning curve and information resources improve, things will get better and better.
EBM has many dimensions which fascinate me, and I’ll be blogging about it a great deal. Stay tuned.