“clinical jazz” harmonizing clinical experience and evidence-based medicine david c. slawson, md...
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“Clinical Jazz”Harmonizing Clinical Experience
and Evidence-Based Medicine
David C. Slawson, MD
Allen F. Shaughnessy, PharmD
Lorne A. Becker, MD
Shaughnessy AF, Slawson DC, Becker L. Clinical jazz: Harmonizing clinical experience and evidence-based medicine. J Fam Pract 1998;47:425-8.
Objectives
• Perceived conflicts between EBM and
clinical experience
• Problems associated with relying solely on
clinical experience- self/experts
• Restructuring into harmony- “clinical jazz”
Wait a Minute! What About Clinical Experience?
“Clinical science and clinical expertise both have their
essential place in medicine. There is potential danger in
attempting to replace one by the other, in banning intuitive
knowledge from the realm of the “rational” and in placing
explicit, quantitative, calculating technique over implicit,
intuitive human understanding as the ideal for clinical
medical knowledge”Gordon DR. Clinical science and clinical expertise: changing boundaries between art and science in medicine. Lock M, Gordon DR, eds. Biomedicine Examined. 1988;Boston, Mass: Kluwer Academic Publishers, 257-95.
Clinical Experience
• The fertile ground from which ideas and
hypotheses grow
• Major conflict: Experience doesn’t jibe
with research-based evidence
Clinical Experience
• Not a source of valid POEMs
• Multiple validity problems
Clinical Experience - Validity
• Latest “bad experience” bias• “Out of sight, out of mind”
– “he would have told me if he was having problems”
• Nonrandom loss to follow up– Dissatisfied customers go elsewhere
• Inability to combine outcome data for multiple patients
Clinical Experience - Validity
• Small sample size
• “Stacking the deck”: Biased allocation to
treatment groups
• “Rose-colored glasses”: Biased
assessment of outcomes
“Reverse Gullibility”
• The story of Semmelweis
– 1847: hand washing decreased obstetric mortality
from 18% to 1.2%
– Virulent attacks lead to asylum commitment
• MDIs vs nebulizers, eye-patches, H. Pylori
(Barry Marshall), home glucose monitors, others
Experience: A problem of perception
• Moral: Clinical experience sometimes prevents seeing the right picture
• Now that you see it, can you try to not see it?
• Moral: Experience can result in ideas that are difficult to change 4
Do you see the Dalmatian in the picture?
www.optillusions.com
Perceptions are difficult to refute
Why is it so hard to
believe that this is
not a spiral but
actually a set of
concentric circles?
http://www.michaelbach.de/ot/ang_frazer/index.html
They really are!
Clinical Experience
Not really in competition with EBM
Combining EBM and Experience: “Clinical Jazz”
Structureplus
Improvisation
Clinical Jazz
Improvisation without structure =
cacophony
Structure without Improvisation=
tedium
Clinical Jazz
Remember “The Expert”
• Expert in diagnosis and procedures (clinical
experience)
• Not necessarily expert in therapeutics (EBM)
– Case series; LOE 4 at best
• The best expert (YODA) combines experience with
the evidence = Clinical Jazz
Valid POEMs Provide the Structure
Clinical Interventions Known to be Harmful
Clinical Interventions of Uncertain
Benefit
Clinical Interventions Known to be
Beneficial
gestational diabetes, bone densiometers, lung cancer screening
Advantages of Information Mastery
• A liberating structure
– Stable (little chance of ping-pongs)
– Simple rules (find the valid POEMs)
• Relatively non-restrictive
– There aren’t that many valid POEMs!
Clinical Improvisation - Opportunities
• Conditions with no valid POEMs
– e.g. Screening for lung cancer
• Conditions with multiple valid POEMs
– e.g. depression
Clinical Improvisation - Opportunities
• Patients whose characteristics differ from
those of patients included in research studies
• Implementation methods for valid POEMs
Clinical Improvisation - Potential Sources of Inspiration
• Clinical Experience
• Colleagues’ Ideas
• Local Experts & Consultants
• “Standard of Care”
• DOEs
• Others
Clinical Improvisation Not a Solo Activity
• Including the patient’s perspective
• Working with a clinical team
• Working with consultants
• Working with partners
“If you can’t listen, you can’t play jazz”
Wynton Marsalis
Using Clinical Experience to Develop Valid POEMs
• For Individual Patients
– N of 1 clinical trials
• For Groups of Patients
– outcomes-based research
1000 people in the community
750 will report an injury/illness
250 will seek care9 admitted
3 referred
1 university admission
Need for Outcomes Research in the Community
White KL, et al. N Engl J Med 1961;265:885-92
Valid POEMs“Outcomes-Based Research”
• Goal: Not to replace clinical judgment, but to give clinicians more information to base opinions and practices.
• “Primum non Nocere”
• “Dualism”- distinction between clinical experience and patient-oriented research is in error
Circle of Clinical Reasoning
Patient seenin practice
OutcomesResearch
ClinicalJudgment
Flaws in the Circle of Reasoning
• Fallacy of Division: What is true of the
whole must also be true of its parts– “Bell curve of clinical response”– Law of Diminishing Return, the “Keflex-
Reflex”
Flaws in the Circle of Reasoning
• Fallacy of Hasty Conclusion: What is true of
the parts must also be true of the whole
– Using evidence from clinical experience to
justify a general approach to all patients,
without applying the rigors of the scientific
method, may result in harm
Why is Medicine Here?• Goals of medicine:
– Relieve/prevent suffering– Maintain/provide hope– Prevent, treat, or cure disease
• The science of medicine:– knowing the best way to prevent, treat, or cure disease– EBM can address this aspect
• The art of medicine:– Determining, using intuition, experience, and judgment,
what patients need the most
• Clinical jazz = science + art
“Mundus Vult Decipi”- “The world wishes to be
deceived”People would rather be
deceived than have the truth create anxiety.
-Caleb Carr, “Killing Time”
“The only sure foundations of medicine are an intimate knowledge of the human body and observations on the effects of medicinal substances on that body”
-Thomas Jefferson
“America’s two greatest gifts to the world are jazz and Medline.”
--Richard Smith, BMJ 2001
The Yin and Yang of Medicine
• Start music
• Rigid enforcement of outcomes-based guidelines
just as misguided as foregoing results of patient-
oriented research
• The seeming opposites of medical practice,
clinical science and clinical experience, are
inseparable
• Structure with improvisation = true art
The Bottom Line
“We may not have all the right answers, but
we need to find and verify those that do
exist; for the rest, we need to ask the right
questions.”
“If we shadows have offended, Think but this, and all is mended, That you have but slumbered here, While these visions did appear. And this weak and idle theme, No more yielding but a dream, Gentles, do not reprehend. If you pardon, we will mend. . . . So good(bye) unto you all.”
William Shakespeare- A Midsummer Night’s Dream
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