Evidence Is Only A Part of Evidence Based Medicine

EBM is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. Clinical expertise refers to the clinician's cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology. 

There are serious subtleties in Sackett's straightforward statement. Has the physician, addressing your problem, necessary cumulative experience? How is relevant cumulative experience defined? How do patients judge a physician's total  education? How does a patient assess a physician's clinical skills?

What are some of the other important issues? Does the physician have a stable personal life? Is he or she in financial difficulty?  Did he or she have a knock-down drag-out fight with his or her spouse or children the night before he or she is scheduled to perform a technically difficult procedure, requiring a sharply focused mind,  for you?  Does the physician use too much alcohol or is he or she a drug-user?  Does he or she have a health problem which affects medical practice and judgment?  Is he or she a personal risk-taker and is that a personality characteristic you consider useful in your care?

Is the physician intellectually aggressive and knowledgable? Is the physician energetic or lazy?  Is the physician inappropriately fearful or self-defensive?  Does he or she seek-out and value the opinions of other physicians in the same specialty or does he or she dismiss those opinions which are inconsistent with his or her views. Does he or she know what evidence is important in your case, obtain that evidence and then carefully review it, integrating it with the available history, physical findings and other medical data about you? Does your physician seek consultation or make referrals or does he or she believe that he or she can "handle it all" even though his or her experience may be very limited?

Does your physician work in isolation? Does he or she test his or her ideas in study groups, professional lectures or other activities? Does he or she read leading medical journals or rely on pharmaceutical company sponsored education programs for updates? Are your physician's extra-curricular activities primarily medical-political, or is he or she focused on activities benefitting the comunity?

Does your physician work in a medical group run or owned by lay people? Are the physicians in the group setting its course or are they only paid employees for whom working conditions, patient volume, practice philosophy, professional standards,  office facilities, and financial production numbers are dictated by others?   Do the physicians in the group carefully observe each other so that substandard care is addressed and high quality care is rewarded? Is referral outside the group discouraged? What are the ethical standards and practices of the group? What is its mission?

"Evidence" is a single factor in a many-faceted  physician-patient relationship.  While the preparation, interpretation and value of medical evidence changes rapidly, the physician's wisdom, personal and professional judgment, compassion and competence in addressing life's issues tend to be stable. Don't get hung-up on evidence. Look for the subtleties.