Saturday, May 29, 2010


Evidence, (not Experience) Based Medicine (EBM)is a new paradigm that has brought a better clarity of diagnosis and treatment to the medical community. Previously, physicians would use anecdotal, inductive reasoning with pathophysiology of disease, previous teaching, with its tremendous prejudice and biases to make clinical decisions in both diagnosis and treatment. Much of how we practiced was never scientifically proven, but taught to us that we took as the Gospel. Some of this included old wives’ tales and consensus opinion. The latter was when a committee of experts in a field voted on how to diagnose and treat. But with EBM the “Evidence” is put through rigorous statistics, reviewed and re-reviewed. This gave physicians the tools needed to enhance their clinical decision, utilizing both theory and statistical modeling. Doctors are discouraged to use their own beliefs and value system and encouraged to be “objective.” Back in 1972, A. Cochrane MD PhD advocated computerized literature for EBM. This is now a reality. Scientific studies are included in the Cochrane database, which as of 2010 has over 3500 systemic reviews and still growing. It is easily accessible to both doctors and their patients. Medline and Pubmed are several of the sites to obtained these on the Internet.

Evidence Base Medicine will always be a work in progress as new studies are completed. Guidelines for diagnoses and treatment are being worked into the fabric of everyday clinical practice. But what about Experience Base Medicine? Does Experience of years of practice count for naught? If the hallmark of good medicine is Evidence Based on double blinded studies involving a large number of patients, then how about the single individual, perhaps you, influence the diagnosis and treatment and what your physician will do to the next patient who has the same medical problem? It is his experience with you and as many others like you that he has in his conscious and unconscious mind that gives him the perspective to make that very unique and personal determination for your best result.

My first clinical rotation as an acting intern was in 1962. Now 48 years later, I may not be any smarter, but I am wiser because of the experience of the years of practice. Of course I review the databases, but the thousands of patients, and tons of medical journals I read along with the hundreds of medical conferences that I participated and attended should and does give me a different perspective on how I practice medicine. After all, Medicine is a science of uncertainty based on the art of probability. Like most practitioners I always want the very best for the patient and unless some catastrophe (stroke, acute mental illness etc) occurs in my life, I am on the top of my game. Despite my years, I practice what I preach and remain as vibrant now as I was fifty years ago.

Quoting from my Medical hero, Sir William Osler, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” He also said “The young physician starts life with 20 drugs for each disease, and the old physician ends life with one drug for 20 diseases.” Also “One of the first duties of the physician is to educate the masses not to take medicine” and “Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.”

So what is Experience? Experience is multifaceted and very fickle. It involves facets of intellect and consciousness which occur in combinations of thought, perception, memory, emotion, will and imagination. Importantly it must also include unconscious cognitive processes that at times are fragmentary and fleeting so they can crystallize over time to produce an original concept. It depends on one’s individual ability to process data, to store and internalize it. The implicit knowledge of clinical experience has been called "knowing in practice.” This method of knowing allows the experienced physician to arrive at a diagnosis after only a few moments of history taking, although it would be difficult to explain the method for arriving at this diagnosis.

Knowing in practice has three important roles in clinical medicine. Diagnostic expertise can only be developed with experience. The development of the motor skills involved in medical practice--feeling an enlarged liver, for example--requires practice as well. Physicians also learn to hear what patients are saying and develop an understanding, “hearing between the lines”. From my years of teaching medical students and young doctors, I know that good doctors are born, not made. Some have it and others will never get it!

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