Lately I’ve been reading material from critics of my chosen profession because I’m trying to become better at what I do. If I know what their criticism is, I can make myself better by understanding both sides and coming up with better solutions. I am constantly prone to settling into my own set of views and when I do that I am not only limiting my own capabilities but I am also depriving others from the chance to learn new things from me. So, duty forces me to break out of my comfortable little world and learn new things from others.

As a healthcare provider this quest has led me to think about how I make medical decisions. Do I use common sense or do I make decisions based on evidence from the literature?

For one reason or another, evidence-based medicine and common sense and are considered by many people to be contradictory. One can be trusted and is considered entirely factual while the other is viewed as entirely subjective and dangerous. As a society we mostly deal with things in black white and this is the norm. But this is entirely unnecessary, there are many shades of gray here, and I’ll explain why I think that’s the case below.

Common sense has its place in any decision-making process but it relies heavily on the deductive reasoning skills of individuals. It is a mixture of facts, beliefs and opinions and it is by nature is mostly subjective. We can find concrete evidence that something is what it appears to be, and we can all agree that it is so, but there is always bias that comes from belief and it is unavoidable. When we rely on common sense to tell us what works and what doesn’t we must then trust the individual who is providing it. Since common sense is subjective and infused with belief, it can be considered useful only when objective scientific evidence is not available. So, we do our best to comb the research to find empirical evidence that supports a diagnostic decision or treatment plan but what happens when that evidence is weak or spurious? We fall back on common sense!!! Why? Because it’s a position of default. We know what we know and we believe what we believe and everything we think, and do is brought forth from that. The more we base our sense in fact, the more sense we have.

Evidence-based medicine is an approach to medicine that uses a weighting system and ranks various types of studies based on statistical outcomes. It is the best tool we have in biomedical research to objectively analyze data to support or deny research questions and apply them to medical practice. The problem is, even these studies introduce bias, and many of the studies are poorly designed. In order to obtain valuable information from a study you need good study design and reliable execution. It is astounding how well we execute studies with the technology we have, but study design is often the problem. Let me give you a quick example.

There are two types of studies with regard to time; prospective studies, which are studies that are completed and observed in real time with a particular goal in mind; and retrospective studies, which are analyses of data from studies that were previously carried out. Dietary studies can be prospective or retrospective. Retrospective dietary studies are worthless because they don’t control for the variables of lifestyle and environmental factors of individua ls and therefore the data derived from them is not reliable in any way. The data from prospective dietary studies can be more useful but only if people are sequestered in a facility where they locked down and all of the food intake is controlled by the researchers. How do know this?

There have been studies done to show that people consistently underreport the amount of food they eat. This finding would invalidate most of the prospective studies that were not carried out in a controlled manner. This means that most of the data we have on dietary studies is worth very little and believe it or not, many, many studies are carried out this way.

The above is just one example of how studies are poorly designed. What’s interesting to note is, we use often use logic and common sense to design the evidence based studies. So, the studies are only as good as the people who design them. Even if studies were designed entirely from computer analysis there would still be logic and common sense behind the design of those computer programs. Okay, so some would say, “we can’t escape it but we can minimize the amount of bias we introduce and that’s what evidence based medicine is trying to do.” I completely agree!!! The problem is, studies are very very expensive to carry out and money always introduces bias. I’ll bitch about financial bias in another blog but please understand it is a huge problem in biomedical science and it cannot be overlooked when considering medical decision making.

So, I guess if I had to take a stand on one or the other, I’d say if someone put up the money, time, and effort to design a study designed with minimal bias I’d go with the evidence of course.

But, I still have to use my brain when there isn’t enough evidence to confidently predict an outcome or enough money to pay for it.

 

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