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Evidence-based medicine and intuition both work
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EVERY health-care system balances coverage, quality and cost — often focusing on one or two at the expense of the others. It is clear that the US has room for improvement in all three areas.
The US Patient Protection and Affordable Care Act (the landmark legislation widely known as “Obamacare”) aims to widen coverage, while so-called accountable care organizations, such as Kaiser Permanente, try to contain costs by aligning the interests of providers and payers.
However, efforts to raise quality through the application of evidence-based medicine (EBM) risk ignoring what we know about human cognition and expertise and may undermine the vital role played by a physician’s expert judgment. There are at least three reasons to be wary. For starters, EBM is grounded in a fundamental distrust of physicians’ intuition.
Physicians develop expertise over many years, and when they have ample opportunities for feedback about their judgments, their intuitions are valuable, particularly in more complex cases. In fact, an experienced doctor’s conclusions may be more accurate than those provided by EBM.
That is because EBM, though based on data from randomized trials and rigorous experiments, is designed for situations that approximate the conditions of patients in those tests. The problem is that when the context changes, the trial results become less reliable.
A second problem with EBM is that it offers little guidance when a medical condition is evolving. For example, acute asthma may be the focus of care at one moment, but might shift to the patient’s diabetes later.
Finally, and perhaps most critically, one must ask how clinicians are to make decisions when there are gaps in the EBM knowledge base.
Indeed, one might wonder how such trials are initiated at all if clinicians do not tentatively explore a problem in the first place. To insist that all treatment decisions be based on existing best practices stifles this exploration and prevents potential medical breakthroughs.
Advocates of EBM respond that it is the job of researchers to generate the data that are turned into best practices; the clinician’s role is to implement the results.
But this approach runs counter to medical history, in which advances come only after practitioners notice anomalies, discover flaws in current “best practices,” or improve on existing approaches. Moreover, important sources of EBM have themselves proved to be misleading.
As we consider a likely future in which physicians adhering to EBM are paid more, we must consider the cognitive limitations and the human cost of unquestioning compliance with so-called “best practices.”
A more effective approach must be to combine EBM with the expertise and intuition of experienced caregivers, and to take the benefits of both.
Devorah E. Klein is a cognitive psychologist working to design medical products. Gary Klein is a senior scientist with MacroCognition LLC. Shawna J. Perry is director for patient safety systems engineering at Virginia Commonwealth University Health Systems. Copyright: Project Syndicate, 2014.www.project-syndicate.org
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