Evidence-Based Medicine vs. Common Sense

I have recently noticed online comments that common sense isn’t very common anymore. I second that. I have written here before about the problems with evidence-based medicine being substituted for physician expertise.

There was a time when physicians could hospitalize patients they thought needed to be hospitalized. We didn’t necessarily have a specific diagnosis in mind to admit them. In fact, we needed to admit them to determine a diagnosis. We knew they were sick, but needed to be able to determine precisely why. Patient hospitalization was for the specific purpose of getting the correct diagnosis and the correct treatment.

The day had not yet arrived when we needed to justify our hospitalization of a patient based upon a three-hour wait on hold to speak with a physician who knew nothing about the patient or talk with a nurse who couldn’t speak English.  We could put patients in the hospital just because we didn’t know what was wrong with them.

We are now face-to-face with the absurd idea that we can’t hospitalize somebody without a diagnosis and that if we guess at a diagnosis, we are setting ourselves up for the accusation of fraud. Meanwhile, the patient is held hostage by a long list of “Captain May I’s” designed to prevent the admission of a patient to the hospital. All topped by the payer’s ability to accuse physicians of fraud if all else fails to prevent the patient’s hospitalization and payment for that hospitalization.

I remember before we had evidence-based medicine. I remember when we were allowed to have common sense, and more importantly, to use it. I remember a time when we would NOT be penalized for telling the truth or for thinking too much.

I once had a patient who made many trips to the emergency room. She presented with vague malaise and a history of chills. She had been seen several times by several doctors and finally her primary care doctor called me and asked me to try to find out what was happening to her.

I listened and examined her. She had a vague fullness in her abdomen and a mildly elevated white count, possibly indicating infection. But I didn’t have a very firm diagnosis, so I admitted her to the hospital. I soon discovered that she had a fever of 103.8° once daily at four in the afternoon. I diagnosed her with a tubo-ovarian abscess on her left side and treated her with intravenous antibiotics, including penicillin, gentamicin, and Cleocin, all fashionable 35 years ago.

The point is that I arrived at the correct diagnosis and the correct treatment because I was able to hospitalize the patient even though initially I didn’t quite understand what was happening to her. And of course, the beauty of this is I treated the patient successfully without being accused of fraud and the patient was grateful. Were we to be held to evidence-based medicine, we really didn’t have a reason to hospitalize this patient because her fever remained undocumented until she was hospitalized. In the hospital I was able to make the right diagnosis and provide the right treatment.

The patient was feeling much better after a week. The antibiotics she received in the hospital killed the organisms living in the abscess, but the abscess did not drain or resolve on its own. A month later I had her return to the hospital and drained the abscess laparoscopically.

To make a long story short, this lady’s successful care occurred because I could hospitalize her even though I couldn’t say exactly what she had. At that time, with hospitalization, I could correctly diagnose and treat her successfully without repercussion or recrimination from payers.

Back then I didn’t need to worry about violating the rules of evidence-based medicine nor did I need to worry about being threatened with charges of fraud. I was simply allowed to treat this patient effectively with good judgment, resulting in a good outcome for my patient.

Forcing patients to go without treatment in order to slavishly follow the rules of evidence-based medicine and adhere to the lock-step of prior authorization causes hugely expensive problems later. The delayed care allows the problem to become worse, sometimes life-threatening. In the end, delayed care costs far more than treating the condition in early stages. Sometimes patients are seriously hurt by delaying needed care until the condition becomes a crisis.

The hallmark of a good physician is the understanding that each patient is different. The basis of a physician’s medical expertise resides in recognizing every patient as a case of one. In medical research, the case of one is disparagingly labeled anecdotal and not to be counted. In the actual practice of medicine, every patient is a case of one, as Hans Duvefelt describes so well in his Substack post “Art and Archetypes in Medicine.”

At least there is some recognition by researchers that all patients don’t fit in neat categories. In the article cited above by Iqbal Ratnani et al. titled “Evidence-Based Medicine: History, Review, Criticisms, and Pitfalls,” the authors raise the issue of trying to lump all patients into one category. 

…critics have suggested that EBM [evidence-based medicine] focuses on groups of patients and does not consider the differences between each patient, subgroup analyses, or patient values and preferences.

Allow physicians to use their medical expertise to solve patient problems. Remove the handcuffs preventing physicians from making medical decisions in the best interest of their patients, whether it’s evidence-based medicine, prior authorization, or all the other “Captain May I’s” preventing physicians from providing the care they know their patients need.