In Part 1 last month, I reasoned why the craft of medicine is dead—or at least dying. And I left opened the question, “What should take its place?”
Considering only 20 percent of medical practice is firmly supported by scientific evidence, and more than 12,500 randomized placebo controlled trials (RPCTs) are published yearly, it’s humanly impossible for individual practitioners to process, analyze, and integrate into practice the vast amount of information accumulating—let alone recognize what’s “proven” vs. only suspected true. Today, more than ever, doctors need to capitalize on expert groups’ consensus statements and guidelines. Expert groups are better equipped to focus on a narrow area of medicine, periodically reviewing research in that field, evaluating the quality of that evidence, and reconciling that evidence with the prior body of knowledge in that field. They can then publish a consensus statement summarizing the evidence and guidelines for Evidence Based Medicine (EBM) care.
Why, given scientific knowledge of the best known way to treat asthma, diabetes, or pneumonia, do we fail to implement that knowledge reliably and consistently? Why, if 65 percent of American internists believe clinical practice guidelines (CPGs) will improve the quality of care, do only 18 percent change their practices to conform with CPGs? There are many practical hurdles.
Unfortunately, there often exists inconsistent evidence in the scientific literature. This has an effect of some physicians not trusting guidelines. Ironically, however, others consider this situation to be precisely where expert consensus guidelines have the most value: based on what is known, what’s the consensus of what constitutes good practice?
Guidelines are based on scientific knowledge and expert consensus. Due to the exponential rise in accumulation of new knowledge, guidelines need updating approximately every three years.
There are often many guidelines existing for specific conditions. Even without writing a consensus guideline, there exists an enormous amount of work and need of special training to determine which guideline to adopt and/or which ones to amalgamate. Most physicians in this country practice in solo or small practice settings and simply don’t have the resources to do this work.
Although I believe most physicians are driven to give patients the best care, it’s a fact that poor care is usually paid for the same as good. For many, this is a disincentive to do the work to provide EBM care.
Computerized clinical decision support tools have tremendous potential to facilitate implementation of EBM guidelines. But these systems often must pull information from multiple disparate systems, requiring difficult or costly programming. To be widely accepted by practicing physicians, clinical decision support tools must present the right information, in the right format, at the right time, without requiring special effort.
These hurdles aren’t insurmountable; it’s imperative that they be jumped. In fact, several organizations, including OSF Healthcare System, have many of the technological tools and the processes in place to implement EBM to maximize the quality and safety of patient care. These efforts are complex and will take considerable resources and time, but progress must be made and is being made. IBI