Is it really true that most clinical decisions have no evidence base?

Question

Can you give some concrete examples? I was perplexed when i read this in this portion (Teach medical students reality to make good doctors) of this site: http://www.bmj.com/cgi/content/full/325/7366/711#resp1

I am an RN and in nursing school was taught rationales for every single intervention!

Answer 1

No, but evidence is limited in a lot of areas, and even when it looks fairly robust, new evidence is often contradictory.
When I was in training, corneal abrasions were routinely treated with an eye patch. There was a solid rationale behind it. Unfortunately, the comparison studies were few, small, and not well-known, and it turned out that patching generally offers no benefit, and indeed is problematic in some cases.
New blood pressure medicines are marketed because they lower blood pressure. But we don't care about lowering blood pressure. What we care about is decreasing the long-term cardiovascular risks associated with hypertension. We obviously don't want to leave effective new drugs in stage III clinical trials for fifty years to see how many in the study and control groups have heart disease in their later years, so we make the assumption that there's always a correlation that may not be there. The same goes for new diabetes drugs. Recently at least one has come under scrutiny because it does a good job of lowering blood sugar but those treated with it have an increased incidence of cardiovascular disease, which is one of the main reasons we're interested in treating type II diabetes to begin with.
You'll find that your "rationales" are a long way from being evidence-based, and the evidence (we hope!) will expand and improve with time. A strong part of the scientific method is that we don't marry concepts, and we always have to be willing to discard the old understandings when new and better ones appear. There's an old doctor's saying: "Be not the first by whom the new is tried, or the last by whom the old is thrown aside." Unless you're in primary research with a solid study protocol, it's a good adage.

Answer 2

Well, I could say that sounds partly true. The medical world at present is making the practice an evidenced-based as much as possible. However, there are lots of things that remain beyond the knowledge of medical experts.

Some mysteries in the human bodies and some of the mechanisms of every disorders or diseases and the different results of their interactions cannot be fully understood at once to arrive to a general definite rule.

What is discovered for now about a certain condition is not absolutely definite as other aspects could remain unknown. As life is dynamic, so are the the activities of every single organism which simply imply that what we know about a certain disease could change every now and then.

So, do not be perplexed. I can tell you that as of today, most clinical decisions are made based on "existing evidences". However, there is no guarantee that those existing evidences are sufficient enough to expect an outcome that someone wishes to be.

There are some situations as well that sounds to be complicated and "unique" which leaves no other option to a medical practitioner but to make a sound clinical judgement based on his existing knowledge. Whatever is the outcome will soon become a new evidence which other will base on in the future.

To sum up with.... We have to understand that in medicine, nothing is definite. Everything changes in due time. That is the reason why every medical practitioner needs to be updated. The books needs to be revised from time to time. You see, what we know from now could instantly change in a short period of time.

Humans cannot be used in experimenting extensively whatever queries someone got in mind. An opportunity to learn something new may just pop up anytime in any case...which becomes a "case report". If you will look closer on it, we can actually see some "indirect trial and error" throughout the practice of medicine.

Examples:
1. Long ago, you should not give pain relievers to a patient with acute abdominal pain. Today, they should be relieved from pain as part of the initial interventions.

2. A highly confusing case that mimics a certain case can be erroneously managed.

You see, medical professionals are just humans and have great limitations on what they know. That is the fact and everyone should acknowledge such existing reality. Such truth should be passed on to the medical students who are learning the concepts and theories of medicine........ that was the thought in that article you read.

Answer 3

Of course many medical decisions are evidence based. But not all disorders are entirely physical. With each major illness comes a truckload of social and psychologic issues. Shakespeare said it best when he had Macbeth query his wife's physician: Cans't thou not minister to a mind diseased, pluck from the memory a rooted sorrow, raze out the written troubles of the brain, and with some sweet oblivious antidote, cleanse the stuff'd busom of that perilous stuff which weighs upon the heart?

Answer 4

1

Answer 5

If the Bible is the real-deal, the Word of God, then we have a book that answers the issues of life. Therefore, it is very important to determine IF the Bible is reliable. The Bible is a collection of 66 books (39 Old Testament, 27 New Testament) written over a period of 1500 years by approximately 40 different authors about creation, history, prophecy and Gods plan for all of creation. This fact is a miracle ALL by itself! How can 40 different authors over a period of 1500 years write a collection of work that doesn't contradict itself?? It can not do this without Divine intervention! Facts and principles such as the earth being round Isaiah 40:22 , earth being suspended in nothing Job 26:7 , valleys in the seas 2 Samuel 22:16 , sanitation Deuteronomy 23:12,13 , quarantine Leviticus 13:45-46 , and blood being the source of life Leviticus 17:11 (DNA) ALL these scientific findings were recorded in the Bible hundreds (sometimes thousands) of years before they were “discovered” by scientists. These are just a few examples, there are many, many more. Who else but God could have revealed such things that were unknown to man – and yet would later be discovered and confirmed? GOD knew because he created them all! Hundreds of prophecies have been documented! Prophecy is a promise from God of what is to come. Unlike other books and false religions whose predictions have come and gone (and failed) the Bible has never missed. Consider Psalm 22:12-18 which describes the crucifixion of Christ. Now consider that this book was written 1,000 years before Christ was even born, and at least 600 years before crucifixion existed! This is just ONE example regarding Jesus, there are hundreds more. Google "fulfilled prophecy" There are many ministries, scientists and historians whose work exclusively deals with prophecy. It seems pretty clear at this point that a book written by so many different people over such a period of time containing all of these undiscovered scientific principles and specific predictions about people, places, and events with 100% accuracy could only be the product of something supernatural - God. He tells us in 2 Timothy 3:16 that he is the author. The Dead Sea Scrolls, discovered in 1947, are an overwhelming source of confirmation. These scrolls contain manuscripts about 1,000 years older than what we previously had... and they all match! It takes a lot more blind faith to ignore the Bible than it does to accept it as divine and reliable. Many intelligent and scholarly skeptics have set out to disprove the Bible and God’s existence only to find overwhelming evidence that God does exist and the Bible is His Word. Jesus says if you seek him honestly He will personally make himself known.