Evidence-Based Medicine in the Information Age

The mouse is often critical to scientific discovery. Nowadays the electronic mouse is also a revered tool. A key player in the evolving field of evidence-based medicine (EBM), it helps physicians delve into scientific data to determine the most effective diagnosis and treatment options for their patients.

 

While EBM dates to the advent of the Internet, this clinical decision-making technique gained widespread use more gradually than the World Wide Web. But over the past 10 years, EBM's advantages have been rapidly garnering nationwide physician support and use.

 

Norman Jensen, MD '65, began his medical practice before the Internet offered rapid access to resources. Today, the professor emeritus of internal medicine at the University of Wisconsin School of Medicine and Public Health (SMPH) enthusiastically uses EBM in his practice - and also teaches the new approach to medical students and residents.

 

Jensen describes EBM as the physician's most logical choice when trying to maximize quality patient care while also ensuring cost-effectiveness in this era of tightly budgeted health care resources.

 

Laura Zakowski integrates evidence-based medicine into her internal medicine practice at UW Health East Clinic, where she teaches residents. Medical students begin learning about the subject in the Patient, Doctor and Society course she co-directs.

"EBM is the habit of critically approaching choices, such as choosing between two different kinds of diagnoses or treatment options," Jensen explains. "One choice might be standard practice and the other might be based on very recent evidence showing that a different method may be more effective or more cost-effective than the traditional way has been."

 

He shares a story of how evidence-based medicine could change physicians' routine choices for good reason - in this case whether to prescribe antibiotics for otitis media.

 

"One of my students brought to our review group the case of a 17-month-old boy with a red, painful ear, presumably an ear infection," he recounts. "In the past, physicians routinely prescribed antibiotics for otitis media, but through EBM techniques, this student found ample current evidence indicating that middle ear infections usually clear up on their own, without antibiotics."  

 

As a result, the group's conclusion was to avoid antibiotics in such cases.

 

Jensen continues, "Using antibiotics is a much bigger dilemma than it used to be. They are costly, have side effects and are producing a lot of antibiotic-resistant bugs in the environment, to the point where our grandchildren and great-grandchildren might get infections that cannot be cured. It's very important for us to use antibiotics critically."

 

Evidence-Based Medicine Benefits Society and Patients

 

While Jensen admits that learning and incorporating evidence-based medicine into one's medical practice takes time - always a precious commodity for physicians - he sees it as beneficial to society as well as patients.

 

He predicts that the related, evolving field of comparative effectiveness research (CER), which relies upon evidence-based medicine, is integral to achieving success in healthcare reform. Not without controversy, the American Recovery and Reinvestment Act, enacted in February 2009, distributes CER-related funding for use by federal agencies - including the Department of Health and Human Services and the National Institutes of Health.

 

Comparative Effectiveness Research will result in a Consumer Reports style of analysis, says Jensen.

 

"Just as a consumer may compare one make of vehicle to another before buying a car, in the future physicians and patients alike will be able to make evidence-based choices about diagnostic tests and treatments more easily," he says.

 

Jensen agrees with President Obama, who asserts that billions of dollars can be saved if physicians get smarter about the way they practice from hour to hour in hospitals and clinics.

 

"Although it will cost money to accomplish health care reform, we could save a huge amount if it is smart reform based on evidence of what works best and is cost-effective," Jensen says.

 

He explains how routine decisions can waste resources.

 

"Traditionally, while screening and monitoring patients for anemia, physicians would order an H&H - hemoglobin and hematocrit - when most of the time just one test or the other would provide the necessary information. Each test costs only $15, but if you figure you have 10,000 doctors in Wisconsin, and each orders an H&H once a day, reducing this by half would save millions of dollars each year."

 

Jensen suggests a solution of having the laboratory draw blood for both tests, but initially run just one test, keeping the extra blood long enough for the doctor to decide whether the second test is warranted.

 

"This prevents a second trip by the patient and avoids running an unnecessary test," he says.

 

MD Curriculum Includes Evidence-Based Medicine Training

 

Jensen and many others incorporate evidence-based medicine training into all years of the School of Medicine and Public Health's MD curriculum, beginning in the year-one basic epidemiology course and continuing in the four-semester Patient, Doctor and Society (PDS) course for first- and-second-year students, as well as in third- and fourth-year clerkships and clinical practice experiences.

 

Laura Zakowski, MD '90, associate professor of internal medicine who co-directs PDS, has integrated evidence-based medicine techniques into her internal medicine practice at UW Health East Clinic, where she teaches residents.

 

Evidence-based medicine techniques help physicians assess the risks and benefits, and determine the appropriateness of relatively common diagnostic and therapeutic techniques, including weighing a newly advertised medication against an older variety at the patient's request, Zakowski explains.

 

EBM is not practical when making decisions in life-threatening situations, when physicians would rapidly and simultaneously order multiple tests, she adds, but it can be used to study and determine whether changes should be made in the management of the next emergency situation that arises. It also is not the most effective tool for researching rare medical conditions.

 

Zakowski describes the typical evidence-based medicine process.

 

"We begin by formulating a clearly worded clinical question," she says. "Next, we use online resources to search the literature and determine if the research results we find are valid."  

 

Key elements to watch for are whether the study was randomized, was free of bias, used a good compilation of patients similar to the patient being seen, and was sponsored by credible sources without any conflicts of interest.

 

Free, user-friendly tutorials are available to learn the evidence-based medicine technique, and medical librarians are a good resource to help physicians refine and confirm the quality of their searches.

 

Zakowski uses the National Library of Medicine's "Pub Med Clinical Queries," which was designed for evidence-based medicine, when teaching medical students and residents. Available free to anyone, the program filters through the vast amount of available literature and helps clinicians locate the best evidence for their patient.

 

"Novices spend more time than experienced practitioners on their searches," says Zakowski. "I tell students that if they are spending more than one hour researching a question, they need to go to a librarian, who can teach them shortcuts and tips for doing a better search."

 

Adds Jensen, "While some advances in medicine can be very costly, EBM is costly not in terms of money, but in terms of time, which may be a challenge for some doctors."

 

He likens this to learning to ski.

 

"When you are 12 years old, you can learn just about anything," he says. "When you're older, you can still learn to ski, it's just more challenging!"

 

Jensen appreciates the time savings offered by using predigested EBM databases, such as "Up to Date" or the "Cochrane Collaboration," which charge physicians a subscription fee.

 

"Clinician-scientists collect evidence on commonly asked questions, then a small group of scientists review the data and offer conclusions for physicians who may not have time to review the many research studies themselves," he explains.

 

Zakowski and Jensen both use evidence-based medicine most commonly on the inpatient wards.

 

"In the inpatient environment, we are often faced with making decisions about new diagnoses and therapies, and because the patient is in-house, we have more time for the research than we do in the outpatient environment," says Zakowski, who learned to use evidence-based medicine during her early 1990s internal medicine residency at Oregon Health and Sciences University in Portland.

 

While it is sometimes quick enough to complete an evidence-based medicine search during an outpatient encounter, it's common for both physicians to turn to the literature after a patient's clinic visit, particularly for complex searches. They then follow up later with the patient regarding recommendations.

 

A final step in the evidence-based medicine process is communicating the evidence to the patient in a way he or she can comprehend.

 

"It's important to understanding each patient's level of health literacy," says Zakowski.  

 

Along those lines, Jensen notes that most patients have difficulty understanding the concepts of risk and probability, terms that often arise in EBM searches. This has led to another line of research about how best to communicate risk and benefit to patients, he says.

 

EBM Should Augment Case Discussions

 

Evidence-based medicine may seem like a major shift, but in fact it's been at work forever as medical advances and new methods of diagnosis and treatment come on board, notes Jensen.

 

"It's all based on some kind of evidence showing that the new is better than the old, and we should change the way we do things," he says.

 

The general practice of medicine changes annually, perhaps monthly, based on evidence, adds Jensen, noting that almost everything he does now is different from his early years in practice.

 

One thing that should not change, however, is case talk among colleagues, Jensen stresses.

 

"Talking with other doctors about patient cases is the oldest form of continuing medical education," he says. "EBM should augment, not replace, this timeless and valuable practice."

 

By Kris Whitman

This article appears in the fall 2009 issue of Quarterly.

Date Published: 11/11/2009