Western “evidence” cannot
take the place of Indian “eminence”
Medicine has undergone a generation change with the
technology savvy younger doctors now coming to the forefront and taking over
from the older doctors. These young doctors have the latest information at hand
about the happenings (researches) in the field of medicine.
Evidence-based medicine has become the norm in
clinical practice today.
In an editorial published in the BMJ in 1996, Dr
David L Sackett and coauthors defined EBM as “conscientious, explicit, and
judicious use of current best evidence in making decisions about the care of
individual patients. The practice of evidence based medicine means integrating
individual clinical expertise with the best available external clinical
evidence from systematic research”.
Evidence-based practice (EBP) incorporates clinical
expertise or skill with best available clinical evidence and patient
expectations and values. It is a dynamic process, which is continually changing
because new studies are being published everyday adding to the existing body of
evidence.
Even the law requires evidence. Bolam test, which
evaluates the standard of care and decide on the adequacy of information
disclosed when deciding cases of medical negligence, is based on experience “…
is not guilty of negligence if he has 'acted in accordance with a practice
accepted as proper by a responsible body of medical man skilled in the
particular act”. And, the adequacy of information disclosed to the patient
for a valid consent, as per Bolam test, must be in accordance with the practice
accepted at that time as considered proper by a responsible body of medical
opinion.
Whereas, the case of Montgomery v Lanarkshire
Health Board decided by the UK Supreme Court is based on evidence.
Doctors in UK are now required to furnish information about all possible risks
associated with a particular treatment, however rare, to the patient “…to
ensure that the patient is aware of any material risks involved in any
recommended treatment, and of any reasonable alternative or variant
treatments”.
Evidence-based medicine relies on scientific
evidence derived from studies, which can be case reports, case series, case-control
studies, RCTs, systemic review, meta-analysis, observational, retrospective.
The methodology of each is different, the sample population is different. The
population differs in terms of ethnic groups, geography, culture, phenotype,
etc. Hence, data cannot be extrapolated from one population to another
population not included in the study, especially of a different ethnic group.
For this reason, international guidelines are not
suitable for India. The heterogeneity of population, different phenotype and
cultural beliefs and practices need to be considered. For example, take the
case of TB. Western data cannot be extrapolated to our population with TB. We
have only recently started to come out with India-specific guidelines.
‘Eminence-based practice’ is based on clinical
experience and wisdom of a person of eminence gathered over many years of
clinical practice. Personal experience is also data, which is unpublished.
Where Indian data is lacking, experience will count.
There will always be a place for “eminence-based”
practice. Even if local evidence is available, but cannot be applied to the
patient or the patient is a complicated case, clinical experience prevails over
evidence.
So does, evidence-based practice trump
eminence-based practice?
No. None can supersede the other. Both need to
coexist with their individual benefits and limitations.
You need to be updated with the latest technologies
and developments in medicine to give the best possible care to your patient,
yet, the value of experience can never be discounted or disregarded.
Eminence-based practice runs the risk of personal bias, which is omitted in
evidence-based practice.
This scenario can be likened to the age-old debate
of young (evidence) vs old (eminence), black hair (evidence) vs gray hair
(eminence), experience (eminence) vs enthusiasm (evidence). There is no clear
winner, no clear loser.
Maa Saraswati, the Goddess of Knowledge, wisdom and
learning. She is shown holding a small Vedic book in one hand, a rosary in the
second and a large Veena in the other two. The small Vedic book indicates that
reading books is important but this alone is not sufficient to gain knowledge.
The small rosary also denotes that one needs to read a subject repeatedly. The
main tool, the large Veena represents practice or Abhyas or experience
or “eminence”.
The practice of medicine is an art (eminence) based
on science (evidence). Hence, the clinical expertise of the doctor and the best
available evidence should be considered together for best patient
outcomes.
Dr KK Aggarwal
National President IMA & HCFI
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