"Gut feel" versus "evidence-based" medicine

[Buckeye]

I didn't understand all the terms used in this article, but I did understand what was being said overall and it's a little scarey.

PCI = angioplasty with or without stenting (I think)
CAD= coronary artery disease


Gut feelings may trump evidence-based medicine when choosing PCI to treat stable CAD

August 16, 2007
San Francisco, CA - Gut instincts may sometimes trump evidence-based medicine when it comes to performing PCI in patients with stable coronary artery disease (CAD), a new study suggests. Cardiologists asked hypothetically about their motives for choosing PCI even in patients who might do just as well or better with medical therapy acknowledged that PCI instinctively seemed a better choice or that past experiences or anticipated regret sometimes guided their decision.
"The apparent gulf between evidence and practice appears to be motivated primarily by emotional and psychological factors," Dr Grace A Lin (University of California, San Francisco [UCSF]) and colleagues write in the August 13/17, 2007 issue of Archives of Internal Medicine.
To heartwire, study senior author Dr Rita F Redberg (UCSF) emphasized that physicians in the focus groups defended their choices despite agreeing on a lack of evidence to support them. "We did try to point out during the focus sessions that PCI was an invasive therapy and there could be complications secondary to invasive therapy. And people still told us that they would feel much worse about a heart attack or sudden death that could have been prevented than a complication of a PCI, even though there are no data that they actually would be preventing a heart attack or sudden death by doing PCI."


Emotional decision-making
Lin and colleagues conducted three focus groups with a total of 20 interventional and noninterventional cardiologists who were asked to discuss three hypothetical case scenarios and describe what course of action they would take. One case involved a 45-year old asymptomatic man with a history of MI and a high calcium score; the second hypothetical case was a 55-year old female smoker with sharp pain in the chest occurring primarily in the evenings and not associated with exercise; the third, a 60-year-old man with no chest pain or shortness of breath who tires early.
Despite reviewing evidence that showed that an invasive approach was not warranted in any of the hypothetical cases, the focus groups generally agreed in all cases that they would send the patient for PCI. Some cardiologists justified their decision by saying that an open artery is always preferable and that they wanted to deliver the best possible therapy, which in their minds is PCI. Others told anecdotes of past patients who had not gotten PCI who went on to have MIs or die suddenly and said that this influenced their subsequent decision-making. Assuaging patient anxiety, particularly if the patient self-referred after obtaining a coronary calcium score, was another driving factor, as was the occulostenotic reflex.
"Once a lesion considered significant was identified, the consensus about current practice was to proceed, in most situations, with PCI at the same time," the authors note. Additional explanations for choosing PCI included medicolegal concerns and technological advancements such as electron-beam computed tomography (EBCT) and CT angiography that persuaded cardiologists to refer for or perform angiography and PCI.
The study authors conducted their study before the results of COURAGE came out in March. According to Redberg, there is a heightened awareness about the lack of benefit of PCI in stable CAD patients in the wake of the COURAGE trial, "but even before COURAGE came out, people really knew that there never had been a study that found a benefit of PCI over medical therapy, and we do report that data in our paper. . . . But COURAGE got a lot of publicity and certainly may have changed the way people think about medical therapy vs PCI for stable CAD."
But Redberg also thinks physicians fail to recognize when they themselves are not basing decisions on evidence, preferring to think that it is others who are acting inappropriately. "I think we have to have some sort of understanding or recognition that there is more than evidence that drives practice. I think most people feel that they practice according to the best evidence, but even when we tried to be quite clear that there is just no evidence to support what people are telling us they would do, I don't think anyone changed their minds. They still felt doing an intervention would be better than not doing one."


Selective evidence-based medicine
An accompanying editorial by Dr Mauro Moscucci (University of Michigan, Ann Arbor) points out that PCI is not without its risks: "Inappropriate procedures will put patients who are unlikely to benefit from the procedure at substantial risk of fatal and nonfatal complications," he writes. As such, Lin et al's work is a "sobering first documentation that the practice of medicine pertaining to PCI might be far from evidence based."
Moscucci's views are echoed by Dr William Boden (Buffalo General Hospital, NY), co-primary investigator for the COURAGE trial, who commented on Lin et al's paper for heartwire.
"This just reinforces that there is an apparent disconnect between clinical knowledge and the belief about the benefits of PCI," Boden said. "The benefits of angioplasty in STEMI patients have created a belief that because the procedure is identical to that which is undertaken electively in stable patients, the benefit that accrues in the acute patients will likewise accrue in the chronic patients, and that has become the conventional wisdom."
Boden worries that a study like Lin et al's will "fly below the radar" of most cardiologists, who should, in fact, use this kind of qualitative research to pause and rethink their own decision-making. "Belief systems trump evidence," he said. "We continue to see example after example of how we really don't practice evidence-based medicine in this country. I like to refer to this as either selective evidence-based medicine or feel-good evidence-based medicine. We love studies that reinforce our preconceived belief systems and we go out of our way to tout their virtues. By contrast, when studies like OAT, ICTUS, or COURAGE come out, everybody is quick to criticize them and is very reluctant to incorporate them into their clinical practice approaches."
Boden continued: "We have this peculiar brand of evidence-based medicine in the US, which is that we embrace studies that reinforce our belief systems and disdain, denigrate, go out of our way to bad-mouth studies that collide with our existing belief systems."

 

[Rich_by_the_Bay]

By way of background, I have spent most of my academic time for the past 15 years teaching EBM and have come as close as I'll ever get to my 15 minutes of fame from stuff I have done in this area. All that by way of saying it's been a professional passion for me.

Disregard of EBM in medical practice can have many causes, often more than one at a time. While there are cynical reasons (more profitable doing it one way v. another), they don't seem to predominate. Rather, it comes from a lack of skill in retrieving the best evidence (searching skills or the time it requires), a lack of skill in interpreting the evidence once it is found, and lastly, ignorance of the best evidence altogether.

Decision skills are very complex and sophisticated and are lacking in my profession. I've written textbooks on this topics but find it maddening to teach. I have a younger colleague who has what seems to be a photographic memory. She can (and often does) spout trivial facts about almost any disease known. Yet when you watch her patient management style, she shotguns (orders way too many tests, flailing around so she doesn't miss even the most unlikely diagnoses), treats impulsively, relentlessly pursues probably spurious unexpected abnormalities, and rarely solicits or incorporates the patient's values or decision-sharing needs.

When residents rotate from her service to mine, they routinely comment on how "different" we are. I can tell that they are energized and almost seem to feel liberated by the contrast. My costs and lengths of stay (according to a survey by a large HMO some time ago) are 30% less than the mean and my outcomes are the same or better. My medical "knowledge" is likely much lower than the young'ns' (though I am skilled at finding and interpreting evidence), but my decision skills are more evolved.

I think there's some hope: the trend toward group practices, protocols, and guidelines usually nudge practice toward evidence; solo and small group practices have the opposite effect. Evidence-based resources where the source of the evidence (the research quality) has been pre-assessed by objective experts are now coming available, so all the doctor has to do is look it up and do it.

Of course all decisions are affected by the patient's idiosyncrasies and values or preferences, and dealing with complex cases requires far more than the best evidence, but if you don't at least start with that, you are doomed to make a wrong move.

Sorry to ramble on, but I find the phenomenon described in the OP to be fascinating and important.

 

[Buckeye]

Hopefully, the resources will be available to everyone so we can "look it up" even if our physician doesn't care to. It's not always easy to find a physician who practices EBM.

 

[Nords]

I have a younger colleague who has what seems to be a photographic memory. She can (and often does) spout trivial facts about almost any disease known.
Yet when you watch her patient management style, she shotguns (orders way too many tests, flailing around so she doesn't miss even the most unlikely diagnoses), treats impulsively, relentlessly pursues probably spurious unexpected abnormalities, and rarely solicits or incorporates the patient's values or decision-sharing needs.
My costs and lengths of stay (according to a survey by a large HMO some time ago) are 30% less than the mean and my outcomes are the same or better.
My medical "knowledge" is likely much lower than the young'ns' (though I am skilled at finding and interpreting evidence), but my decision skills are more evolved.

Which skills are rewarded by the medical-school instructors?

Which skills is she getting paid a bonus to evolve?

 

[Rich_by_the_Bay]

Which skills are rewarded by the medical-school instructors?

Which skills is she getting paid a bonus to evolve?

Good questions. These are competencies that are not uniformly valued or incentivized. They are role-modeled and discussed. The payoff is to induct the students and residents. For faculty it may be too late.

I'm sure you have analogies in your career - certain styles of leadership or performance that are hard to define, but make all the difference. I theorize that a lot of it is (or is not) part of people's personalities.

 

[Sandy]

From a policy standpoint, I have been in lots of discussions on whether/when/how to incentivize or require physicians to use EBM to help improve patient care while also controlling state spending on medical services.

Practitioners often strongly resist being asked to follow standard protocols arguing that these do not apply to their patients/situations, are inconsistent with their experiences, etc. So, to promote change in practice, the incentives and encouragement must be done in a way that are not threatening or judgemental and do not jeopardize practitioner's perception of autonomy and professionalism. Tall order.

 

[Rich_by_the_Bay]

Practitioners often strongly resist being asked to follow standard protocols arguing that these do not apply to their patients/situations, are inconsistent with their experiences, etc. So, to promote change in practice, the incentives and encouragement must be done in a way that are not threatening or judgemental and do not jeopardize practitioner's perception of autonomy and professionalism. Tall order.

I agree with your synopsis. Sometimes, deviation from EBM is quite appropriate given the infinite number of variables for each patient. But too often, EBM is not adhered to when it should be.

An interesting insight is that ultimately it's the physician who is primarily accountable for the outcomes and anything that goes wrong. Given the sometimes onerous responsibility, it can be understood that if "someone tries to tell me how to practice" they will get a cool reception - "you wanna do it, you take the patient and the accountability."

Furthermore, EBM sometimes varies from the community standard of practice (the standard of practice is wrong). Yet from a malpractice defense perspective, adherence to the community (or state or national) standard of care is your first line of defense. Example: head CT scan has been shown to be of little or no benefit after certain types of mild head injury. Yet the CT is routinely done (minimal risk, high cost). Suppose you follow the EBM standard and omit the head CT appropriately. If even one patient out of thousands has some abnormality that would have been detected by the CT, you are vulnerable. (Of course that disregards all the incidental findings on CT that generate useless wild goose chases.)

So, I am understanding of my colleagues - there are a lot of competing mandates which sometimes are self-contradictory. A national initiative toward standardizing selected aspects of care would be helpful, with some sort of protection from liability if they are adhered to appropriately even when things go wrong.

 

[FinallyRetired]

Suppose you follow the EBM standard and omit the head CT appropriately. If even one patient out of thousands has some abnormality that would have been detected by the CT, you are vulnerable. (Of course that disregards all the incidental findings on CT that generate useless wild goose chases.)

Gee, that sounds like the medical merry go round I've been on lately. I would much rather have the option, as a patient, to assume my own risk of not doing a CT and missing some rare abnormality, versus having the CT and possibly starting a useless wild goose chase. As a patient, however, I don't recall ever being given that choice, I'm just told that I'm being referred to such and such a specialist for further tests and diagnoses. I suppose I could opt out of further testing, but it's difficult when one doesn't have the information on which to make an individual decision on the risks. Of course, there are clear cut times when I need a doctor to tell me that I have a condition that needs to be treated. But so many other times just seem like CYA fishing expeditions and lead to needless worry and carry their own risk.

 

[Rich_by_the_Bay]

Gee, that sounds like the medical merry go round I've been on lately. I would much rather have the option, as a patient, to assume my own risk of not doing a CT and missing some rare abnormality, versus having the CT and possibly starting a useless wild goose chase. As a patient, however, I don't recall ever being given that choice, I'm just told that I'm being referred to such and such a specialist for further tests and diagnoses. I suppose I could opt out of further testing, but it's difficult when one doesn't have the information on which to make an individual decision on the risks. Of course, there are clear cut times when I need a doctor to tell me that I have a condition that needs to be treated. But so many other times just seem like CYA fishing expeditions and lead to needless worry and carry their own risk.

Well said.

I involve patients in these decisions all the time. I tell my students that I never intentionally practice defensive medicine, but I often practice defensive documentation.

"Discussed risks and benefits of CT including incidental findings leading to further testing, small possibility of overlooking bleeding or other serious conditions if we fail to do this test. Good understanding was expressed and pt prefers to omit the test with good insight. To call at once for any unexpected symptoms."

I have no idea if that would protect me (or the patient), but it's how I do it (stress tests, PSA test, and lots of others are common examples).

 

[cho oyu]

Well said.

I involve patients in these decisions all the time. I tell my students that I never intentionally practice defensive medicine, but I often practice defensive documentation.

"Discussed risks and benefits of CT including incidental findings leading to further testing, small possibility of overlooking bleeding or other serious conditions if we fail to do this test. Good understanding was expressed and pt prefers to omit the test with good insight. To call at once for any unexpected symptoms."

I have no idea if that would protect me (or the patient), but it's how I do it (stress tests, PSA test, and lots of others are common examples).

I'm impressed that you take this approach with all of your patients. I do have a question - do you find that there are a large number of patients who wish to completely abdicate responsibility to you and not be involved in the process?


Returning to the concept of EBM, there does seem to be a difference in mindsets between the medical and scientific fields. Working with MD/PhDs in a research environment, I have consistently heard complaints about both the thought processes and decisions made by pure MDs (gut feeling as opposed to evidentiary decisions as described in the above article). Of course, you generally hear more of the negative stories than positive stories.

I'm sure some of this is from training and environment, but I also wonder if this also has something to do with the type of people the field attracts?

 

[Rich_by_the_Bay]

do you find that there are a large number of patients who wish to completely abdicate responsibility to you and not be involved in the process?

Medicine operates in a world of uncertainty. We usually don't have the luxury of being sure. It's probabilities, not certainties. Maybe that partly explains the gap between engineers or researchers on the one hand, and clinicians on the other. Throw in the emotional and spiritual needs of the patients and families, and it really is a very subjective profession even when you do follow the evidence.

Lots of patients say, "whatever you say, doc." I oblige but not until I have presented the same facts I would to any other patient -- only difference is that I add, "that's what I would do, though that doesn't necessarily make it right for you."