Anecdotes, Outcomes, and Evidence-Based Medicine
Go to a grand rounds or medical conference and listen. What do you hear? In most discussions of patient care, clinicians relate compelling anecdotes typically beginning with “I once had a patient who…” Fill in the blank.
The problem is that well-intentioned advice conveyed with anecdotes is often based on specific individual experiences, either positive or negative, garnered in the trenches, caring for individuals with heterogeneous disorders.
No doubt, our practices are influenced and sometimes improved by the anecdotes of seasoned veterans. Moreover, those who do not heed collegial advice risk collective criticism. Most clinicians, however, recognize the inherent variability of a given disease in a particular patient and know intuitively that anecdotes, while instructive, should not be the basis for making decisions.
Enter the budding era of evidence-based medicine (EBM). The goal of EBM is to guide individual clinicians' decisions through the use of current best data. This frequently involves consensus workshops where experts extensively review the medical literature and develop practice guidelines as a reference for evidence-informed medical decision making.
Groups such as the National Comprehensive Cancer Network have established practice guidelines in oncology (www.nccn.org) based on three levels of evidence: level 1 (uniform consensus based on high level data), level 2 (no major disagreements exist based on lower level evidence) and level 3 (major disagreements on management exist).
Unfortunately many clinicians see guidelines as an indirect threat to judgment and worry about the medico-legal implications of practicing outside them. Moreover, even when level 1 data are available, such as the positive prospective randomized trial of neoadjuvant chemotherapy for muscle invasive bladder cancer (N Engl J Med. 2003;349:859-866), the medical community often ignores these data in clinical practice.
It has been said that good judgment comes from experience that comes from bad judgment. Perhaps better judgment comes from outcomes not anecdotes. EBM approaches are critical to quality medicine, and physician researchers must lead the way in thought and deed.