How To Make Evidence-Based Medicine Work

No one seems to understand just what evidence-based medicine is, and right now that is its biggest problem.

That was the consensus at Thursday’s conference in the Capitol Building — “Right Care, Right Time, Right Place” — put on by the New America Foundation and sponsored by the Assembly and Senate health committees.

“Clearly, over time, physicians need to learn to embrace evidence-based medicine. But more importantly, consumers need to embrace it, and understand it.” That’s according to Richard Baker, chair of the Council of Scientific Affairs for the California Medical Association and dean of the College of Medicine for Charles Drew University of Medicine and Science in Los Angeles.

The goal of evidence-based medicine is to use scientific information to provide guidelines for making clinical decisions. By supplying peer-generated best practices to medical decisions, the hope is to have consistently better outcomes for patients and, in the long run, to save time and money. The controversy in the system comes from a fear that having specific protocols for treatment would somehow limit treatment choices for patients and push a cookie-cutter approach on physicians.

Panelist Maribeth Shannon of the California HealthCare Foundation (which publishes California Healthline) said survey evidence shows that misconceptions are the norm when it comes to acceptance of evidence-based medicine.

“There is a lack of understanding among consumers of the key terms. They don’t know what medical evidence is,” she said. And that makes people wary of evidence-based medicine — even though it could improve the health of a large number of patients, many people want a more individual approach. It’s human nature to want their own care to be different or better than most people’s care, Shannon said.

“They want health care tailored to their particular situation, when in reality there may be a right answer for most people,” she said. “They also think innovation equals better care — people think something new is better than something that’s been around for a long time and kind of proven.”

The root of evidence-based medicine is information.  A major task of evidence-based medicine is sorting-out a mountain of medical information, said Sharon Levine of the Permanente Medical Group.

“Look, every one in medicine wants to do the right thing. But for the most part, physicians are on their own to figure it out,” she said. “The evidence-based system supports clinicians by providing unbiased information. And providing information at the right time is very powerful. You have peer-reviewed preferences right there on the desktop in the office. Being able to respond to patients’ questions right there, that’s very powerful.”

It all starts with altering how medical students are taught, according to Baker. Because, he said, the majority of what students learn could be obsolete by the time they graduate.

“We really need a different process to train doctors and residents,” Levine said. “When I went to medical school, the premium was on memory. The person who did the best is the one who remembered the most stuff.”

And no matter how much continued medical education physicians take, she said, “I think we all practice pretty much the way we were trained. But now, I think, there are new skill sets that physicians need to acquire.”

By utilizing and relying on peer-reviewed recommendations, physicians would become better clinicians, she said. But there’s a barrier, she said, where physicians don’t want to blindly trust other doctors’ clinical opinions, and they have a natural wariness that those opinions could be based on saving money. And from the patient perspective, they want their own doctor making decisions about their care, rather than trusting a standard recommended protocol.

“There are significant challenges and barriers to evidence-based medicine,” Baker said, “but we have made progress, we’ve moved forward. What’s important is that we’ve embarked on the process. People are beginning to understand that having a trusted source of information actually informs consumer choice, gives people more treatment choice.”

But, he said, both patients and physicians will need to develop specific skills they didn’t use before. If many patients are going to be involved in their care decisions, communication needs to be crystal clear.

“Evidence-based health care is a paradigm shift,” Baker said. “Everyone needs to be highly sensitive to the skilled use of information.”