Kent Bottles: We Need Both Evidence-based Medicine and Patient-based Medicine

Sometimes I feel as though I am trapped between two worlds that should know each other better and that definitely need each other.  And yet, these two worlds seem to be made up of good people who mean well, but who also talk past each other.  They really do not understand each other at all.

To foster such communication and understanding, I will moderate a panel entitled “Evidence-based Medicine vs. Experience-based Medicine: Are Both Needed?” at the 13^th Annual ICSI/IHI Colloquium to be held on May 3-5, 2010 in St. Paul, Minnesota. (http://bit.ly/Ws7IE)

I have a foot in both of these worlds, and feel caught between two different groups who should really know each other much better because they both are important for clinical care.

As a pathologist and the president of ICSI, a supplier of evidence-based medicine protocols and guidelines, I am professionally most comfortable in the world that wants to make sure that the treatments and advice that physicians give patients are up to date and based on rigorous scientific studies.

This evidence-based medicine world is disease oriented and considers the randomized clinical trial as the gold standard.   Randomized clinical trials are by design not patient-centered.  “Patients who are too old, too young, too illiterate, or suffer from co-morbidity or concurrent psychiatric disturbances are excluded from the study, because the statistical power could be reduced by those characteristics.” (http://bit.ly/aBPk3K) Randomized clinical trials are really more doctor-centered than patient-centered.

As a patient, I also know that guidelines and evidence are not the whole story when it comes to my care.  I recently met with my internist, and decided not to follow his advice on some tests he wanted to order.  I agree with Glass who wrote in JAMA that physicians should follow the evidence-based medicine guidelines, but not in a way that neglects the uniqueness of each patient as a person. (http://www.ncbi.nlm.nih.gov/pubmed/8531312)

We need to follow Moira Stewart’s advice that the patient is more than his or her disease and contrast a disease-centered with a patient-centered approach. (Stewart M, et al Patient-centered Medicine, Thousand Oaks: Sage, 1995) Another useful way to think about this problem is to contrast patient-centered medicine with doctor-centered medicine.  Physicians should be sensitive to patients’ preferences and provide them with the knowledge needed to make the right clinical decision for that unique patient.

Charles Ornstein, president of the Association for Health Care Journalists, in a letter to the Joint Commission recently highlighted the problem that ignoring the need for patient-centered care can cause.  The Joint Commission’s web site is not patient friendly.  It is hard to tell which hospitals have less than full accreditation.  The historical records of hospitals are not available, and hospitals whose accreditation are conditional or at risk of being denied are listed as having “The Gold Seal of Approval.” (http://bit.ly/b6aoiG)  Michael Millenson sees part of the problem as being that Dr. Mark Chassin of the Joint Commission is focused on doctor-centered care more than patient-centered care. (http://ow.ly/1k7KS)

We need to have both evidence-based medicine and patient-centered medicine. Jozien Bensing has proposed at least two ways to start to bridge the gap. Evidence-based medicine should incorporate patient preferences in randomized clinical trial designs and patient-centered medicine should become more evidence-based. (http://bit.ly/aBPk3K)   We need to support both worlds and bring them together.

At the Colloquium panel in May (http://bit.ly/Ws7IE), Ben Heywood of PatientsLikeMe, Jen McCabe of Contagion Health, and ePatient Dave will argue for Participatory Medicine and Experience-based Patient-centered Medicine.  Peter Alperin, MD of Archimedes, Scott Weingarten, MD of Zynx, and David Shulkin, MD will discuss why Evidence-based Medicine is so critical to excellent patient clinical care.

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