[Rich_in_Tampa]

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.