Can EBM and clinical judgment be friends?

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Can EBM and clinical judgment be friends?

My last post seems to have been well received, and I am sincerely grateful for the feedback.  So I hope I’m not being too fastidious or improperly fussy if I take some time here to clarify a particular remark that readers have made in response to the article, either on social media or in the comments section of the post.

And the remark is one generally expressing the following idea:  “Indeed, EBM has serious limitations, we’ve gone too far, and we should make sure to use both EBM and clinical judgment when we are making our medical decisions.”  In other words, art and science.

I understand the tendency for equipoise and the desire not to throw the EBM baby with the bath water, so-to-speak.  Besides, we all know that our clinical judgment is fallible, so it would be foolish to let it rule unfettered.

The problem is that by considering EBM and clinical judgment as proportionate partners in the pursuit of clinical excellence, one commits a conceptual error, because EBM and judgment are not on the same plane: the one provides data, the other is the actual decider.

Part of the confusion, I think, is because we frequently employ the loose expression “to use judgment,” as if judgment was one of the inputs that goes into the medical decision.  The correct formulation is to exercise judgment, i.e., to make a decision.  Otherwise, deciding when or what clinical judgment to use would be a “meta” decision which itself might be subject to the same fallibility as the one we try to avoid when we aim to give proportionate weight to EBM and to clinical judgment.

The truth, then, is that EBM must be subservient to clinical judgment because, at the end of the day, EBM is just a data point among many points that the clinical judge must consider before acting.

The EBM data point is the one that says: “one average, for people who have characteristics X,Y, and Z shared by Mrs. Jones here present, x percent benefit from therapy A whereas y percent benefit from therapy B, and the rates of side effects with A or B are such and such.”

Other data points to consider are Mrs. Jones’ particular circumstances, the doctor’s particular circumstances (e.g., “Am I too tired to operate?”), and others that might influence the outcome, including whether the calendar date happens to be a Friday the 13th.

If EBM could possibly be considered to operate on the same plane as clinical judgment, it would mean that, on occasion, EBM can compel a medical decision.  But even the staunchest defenders of EBM methodology would concede that that could never be.

EBM, then, is always the handmaiden to clinical judgment.  Clinical judgment appreciates the services of EBM, and will use them as it sees fit.

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