Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-77c89778f8-m8s7h Total loading time: 0 Render date: 2024-07-18T06:42:33.962Z Has data issue: false hasContentIssue false

12 - Challenges for evidence-based diagnosis

Published online by Cambridge University Press:  04 August 2010

Thomas B. Newman  and
Michael A. Kohn
Thomas B. Newman
Affiliation:
University of California, San Francisco
Michael A. Kohn
Affiliation:
University of California, San Francisco
Get access

Summary

Introduction

We wrestled for a long time with the question of whether to include the term “evidence-based” in the title of this book. Although both of us are firm believers in the principles and goals of evidence-based medicine (EBM), we also knew that the term “evidence-based” would be viewed negatively by some potential readers (Grahame-Smith 1995; Lancet 1995; Healy 2006). We decided to keep “evidence-based” in the title and use this chapter to directly address some of the criticisms of EBM, many of which we believe have merit. We also recognize that, as elegant and satisfying as evidence-based diagnosis is, there are some very real barriers to applying it in a clinical setting. These barriers are the second topic of this chapter. Finally, we end the book with some thoughts on the future of evidence-based diagnosis and why it will be increasingly important.

Criticisms of evidence-based medicine

EBM overvalues randomized blinded trials and denigrates other forms of evidence, including clinical experience

EBM is frequently misrepresented as requiring randomized blinded trials (or better yet, a systematic review of such trials) to prove that a treatment is useful. This has been humorously illustrated in a “systematic review” of “Parachute Use to Prevent Death and Major Trauma Related to Gravitational Challenge” (Smith and Pell 2003). The authors found no controlled trials of parachute use for the “gravitationally challenged” (people jumping out of airplanes) and concluded that “everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.”

Type
Chapter
Information
Evidence-Based Diagnosis , pp. 239 - 254
Publisher: Cambridge University Press
Print publication year: 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Armstrong, K., Moye, E., et al. (2007). “Screening mammography in women 40 to 49 years of age: a systematic review for the American College of Physicians.” Ann Intern Med 146(7): 516–26.CrossRefGoogle ScholarPubMed
Bornstein, B. H., and Emler, A. C. (2001). “Rationality in medical decision making: a review of the literature on doctors' decision-making biases.” J Eval Clin Pract 7(2): 97–107.CrossRefGoogle ScholarPubMed
Brewer, N. T., Chapman, G. B., et al. (2007). “The influence of irrelevant anchors on the judgments and choices of doctors and patients.” Med Decis Making 27(2): 203–11.CrossRefGoogle ScholarPubMed
Burt, C. W. (1999). “Summary statistics for acute cardiac ischemia and chest pain visits to United States EDs, 1995–1996.” Am J Emerg Med 17(6): 552–9.CrossRefGoogle Scholar
Cahan, A., Gilon, D., et al. (2003). “Probabilistic reasoning and clinical decision-making: do doctors overestimate diagnostic probabilities?” QJM 96(10): 763–9.CrossRefGoogle ScholarPubMed
Cahan, A., Gilon, D., et al. (2005). “Clinical experience did not reduce the variance in physicians' estimates of pretest probability in a cross-sectional survey.” J Clin Epidemiol 58(11): 1211–6.CrossRefGoogle ScholarPubMed
Cardall, T., Glasser, J., et al. (2004). “Clinical value of the total white blood cell count and temperature in the evaluation of patients with suspected appendicitis.” Acad Emerg Med 11(10): 1021–7.CrossRefGoogle ScholarPubMed
Croskerry, P. (2002). “Achieving quality in clinical decision making: cognitive strategies and detection of bias.” Acad Emerg Med 9(11): 1184–204.CrossRefGoogle Scholar
Croskerry, P., and Wears, R. (2003). Safety errors in emergency medicine. In: Emergency Medicine Secrets. Markovchik, VJ and Pons, PT. Philadelphia, PA, Hanley and Belfus.Google Scholar
Davison, G., Suchman, A. L., et al. (1990). “Reducing unnecessary coronary care unit admissions: a comparison of three decision aids [see comments].” J Gen Intern Med 5(6): 474–9.CrossRefGoogle Scholar
Dawson, N. V., and Arkes, H. R. (1987). “Systematic errors in medical decision making: judgment limitations.” J Gen Intern Med 2(3): 183–7.CrossRefGoogle ScholarPubMed
Detmer, D. E., Fryback, D. G., et al. (1978). “Heuristics and biases in medical decision-making.” J Med Educ 53(8): 682–3.Google ScholarPubMed
Dolan, J. G., Bordley, D. R., et al. (1986). “An evaluation of clinicians' subjective prior probability estimates.” Med Decis Making 6(4): 216–23.CrossRefGoogle ScholarPubMed
Eddy, D. M. (1982). Probabilistic reasoning in clinical medicine: problems and opportunities. In: Judgment Under Uncertainty: Heuristics and Biases. Kahneman, D., Slovic, P., and Tversky, A., editors. Cambridge, Cambridge University Press, pp. 249–267.CrossRefGoogle Scholar
Gorman, C. (2007). “Are Doctors Just Playing Hunches?” Time Magazine. February 15, 2007.Google ScholarPubMed
Groopman, J. (2007). How Doctors Think. New York: Houghton Mifflin.Google Scholar
Grahame-Smith, D. (1995). “Evidence based medicine: Socratic dissent [see comments].” Br Med J 310(6987): 1126–7.CrossRefGoogle Scholar
Hayward, R. (2008). “Access to clinically-detailed patient information.” Med Care 46(3): 229.CrossRefGoogle ScholarPubMed
Healy, B. (2006). “Who Says What's Best?” U.S. News and World Report.Google ScholarPubMed
Humphrey, L. L., Helfand, M., et al. (2002). “Breast cancer screening: a summary of the evidence for the U.S. Preventive Services Task Force.” Ann Intern Med 137(5 Part 1): 347–60.CrossRefGoogle ScholarPubMed
Kahneman, D., Slovic, P., et al. (1982). Judgment Under Uncertainty: Heuristics and Biases. Cambridge, Cambridge University Press.CrossRefGoogle Scholar
Knottnerus, J. A., and Weel, C. (2002). General Introduction: evaluation of diagnostic procedures. In: The Evidence Base of Clinical Diagnosis. Knottnerus, J. A., editor. London, BMJ Books, pp. 1–18.Google Scholar
Kohn, M. A., Kwan, E., et al. (2005). “Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain.” J Emerg Med 29(4): 383–90.CrossRefGoogle Scholar
Lancet, (1995). “Evidence-based medicine, in its place.” Lancet 346(8978): 785.Google Scholar
Merenstein, D. (2004). “A piece of my mind. Winners and losers.” JAMA 291(1): 15–6.Google ScholarPubMed
Newman, T. B., and Maisels, M. J. (2000). “Less aggressive treatment of neonatal jaundice and reports of kernicterus: lessons about practice guidelines.” Pediatrics 105(1 Pt 3): 242–5.Google ScholarPubMed
NIH (1997). “NIH Consensus Statement. Breast cancer screening for women ages 40–49.” NIH Consens Statement 15(1): 1–35.
Pantell, R. H., Newman, T. B., et al. (2004). “Management and outcomes of care of fever in early infancy.” JAMA 291(10): 1203–12.CrossRefGoogle ScholarPubMed
Phelps, M. A., and Levitt, M. A. (2004). “Pretest probability estimates: a pitfall to the clinical utility of evidence-based medicine?” Acad Emerg Med 11(6): 692–4.CrossRefGoogle ScholarPubMed
Raiffa, H. (1968). Decision Analysis: Introductory Lectures on Choices Under Uncertainty. Reading, MA, Addison–Wesley.Google Scholar
Smith, G. C., and Pell, J. P. (2003). “Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.” Br Med J 327(7429): 1459–61.CrossRefGoogle ScholarPubMed
Sox, C. M., Koepsell, T. D., et al. (2006). “Pediatricians' clinical decision making: results of 2 randomized controlled trials of test performance characteristics.” Arch Pediatr Adolesc Med 160(5): 487–92.CrossRefGoogle ScholarPubMed
Tierney, W. M., Roth, B. J., et al. (1985). “Predictors of myocardial infarction in emergency room patients.” Crit Care Med 13(7): 526–31.CrossRefGoogle ScholarPubMed
Tversky, A., and Kahneman, D. (1974). “Judgment under uncertainty: heuristics and biases.” Science 185: 1124–31.CrossRefGoogle ScholarPubMed
US Preventive Services Task Force (2002). “Screening for prostate cancer: recommendation and rationale.” Ann Intern Med 137(11): 915–6.CrossRef
Woolf, S. H., and George, J. N. (2000). “Evidence-based medicine. Interpreting studies and setting policy.” Hematol Oncol Clin North Am 14(4): 761–84.CrossRefGoogle ScholarPubMed

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×