Written by Curtis Henderson (Marquette D3)
“Breaking news: ‘An apple a day’ may not keep the doctor away – new study claims no evidence for the health benefits of apples. Also, a look inside the decades long close relationship between the U.S. Apple Association and the American Medical Association.”
In the era of fake news, it may be prudent to establish that this is not a real news headline. However, it’s not entirely implausible. A recent Google News search with the keywords “evidence-based practice” led me to a New York Times article discussing the lack of evidence for thousands of medical treatments and a MarketWatch article offering advice for avoiding “treatment you don’t need or may not work”. It’s not hard to find weekly examples of this that make you think your great-grandfather who never went to the doctor wasn’t so crazy after all. And if you don’t think dentistry is under scrutiny, think again. In a recent article in The Atlantic, Ferris Jabr writes that dental medicine isn’t much of a science at all. Ouch.
There exists a double-edged sword in media reporting on evidence-based practice. On the positive side, it’s an important topic that deserves attention. Evidence is a crucial aspect of healthcare, and without it, billions of dollars are wasted every year on overtreatment and millions of people receive drugs that aren’t helping them. The consequences of not following evidence-based guidelines can cost patient lives. This should be a concern for anyone who cares about improving the quality, safety and cost-effectiveness of healthcare.
On the other hand, very few journalists seem to understand what ‘evidence-based practice’ is and is not. If they do understand, they aren’t bothering to inform their readers that scientific evidence is only one aspect of a clinician’s recommendation. Sensationalist headlines, shocking statistics, and cherry-picked statements from systematic reviews give the impression that healthcare is full of quacks and the science is unreliable. An informed consumer with a healthy skepticism is good, but who benefits from being terrified to see their provider?
Evidence-based healthcare originated in the late 70’s with the work of White, Cochrane and Illich (the same Cochrane of Cochrane Reviews) who desired an improved assessment of the effectiveness of healthcare interventions. In the early 90’s, Gordon Guyatt coined the phrase “evidence-based medicine” and the dawn of a new era in healthcare emerged where “decisions are based on the best available evidence obtained through robust research methods”. This definition was later deemed inadequate and was revised to “the integration of best research evidence with clinical expertise and patients’ values”. This more contemporary version is now widely accepted by and taught to healthcare professionals.
The differences between these two definitions are enormous and perfectly demonstrate the problem with journalism on this topic. The first definition fits perfectly into the narrative of most reporting – that scientific evidence is the be-all and end-all of clinical practice. Unfortunately, that’s the definition that seems to have stuck. This leads us to believe that healthcare is a black and white industry that would best be served by automatons. The latter definition eloquently describes the balance between scientific evidence, a clinician’s judgement, and the individuality of patients. This three-tiered system puts the provider and patient in equal footing with research, creating a healthcare system where scientific evidence helps to inform our decisions but does not dictate them.
If you’re uncertain which system you’d prefer, let’s take a look at what is considered the gold standard of research, the randomized controlled trial. These types of studies provide reliable evidence but are expensive and can take several years if not decades to complete. The reality is that if your providers waited for the evidence gained from such trials before recommending therapy, your treatment options would be more limited, and it is likely the intervention would no longer be relevant due to new advances entering the market. Providers often look at preliminary data to determine whether or not to try something new. If this weren’t the case, there would be a lack of healthcare innovation and a stifling of research on newer modalities.
This may be even more true for dentistry which heavily relies on new techniques and materials. Consider digital dentistry and its materials. Many of the long-term studies are still ongoing, but it has already been put into practice. This technology is already revolutionizing the way we practice dentistry and can provide patients a better experience and outcome. If dentists were unwilling or not allowed to integrate digital dentistry into their practice until all the evidence was available, the dental tech companies would go bankrupt and dental medicine would remain stagnant.
You may argue that you’d prefer a few treatments with high-quality evidence over many treatment options with lower-quality evidence. Let’s remember that even the best designed study still makes generalizations that can often be difficult to apply in clinical practice. Guidelines and standards of care are important, but sometimes require deviation depending on patient circumstances. We should strive for healthcare that is more individualized because every patient encounter is unique. The future of personalized or precision medicine is promising, leading to better diagnoses, earlier interventions, more-efficient drug therapies, and customized treatment plans.
Often underneath these damning healthcare reports exist this sentiment that doctors are untrustworthy. The backdrop of the aforementioned “Is Dentistry a Science?” article is the story of a dentist who overtreated his patients for monetary gain. Let’s be clear – the abuse of power and authority as a healthcare provider is unethical. But perhaps this fixation in the media on evidence-based practice, or lack thereof, is a result of the uncomfortable truth that we oftentimes avoid – sometimes we simply do not know the answer. The reality is that we often work in uncertainty and have to make decisions based on our experience because of limited evidence. However, that shouldn’t erode the trust in the people who take care of others.