On page 380 of this issue of The journal of family practice, Dr. William Cayley highlights one of the major challenges of evidence-based medicine: translating evidence for patients in a way that is not unduly influenced by our own values, biases, and expectations. We face this challenge every day.
Recently I saw a patient with uncomplicated low back pain who wanted me to prescribe a muscle relaxant. Another person, after experiencing a first episode of major depressive disorder, requested lifelong antidepressant therapy. An older woman wanted advice about treatment for shingles.
The difficulty I encountered lay neither with the availability of authoritative, explicit evidence-based summaries on these topics, nor with my knowledge of the evidence in these areas. The dilemma was that most studies, I suspect, were of patients unlike the 3 individuals in my care, and that I had little more than anecdotal information about the potential harms the interventions might cause these patients. Moreover, in such instances, how much should patients’ preferences count?
Should I divulge that trials of muscle relaxants are equivocal at best, and share my belief that muscle relaxants do little more than make a person sleepy?1 How should I frame the current recommendation that maintenance therapy for depression be considered after the second or third episode of major depressive disorder?2 And, for the woman with herpes zoster, what to make of the tradeoffs of various therapies versus watchful waiting?3
All this information to convey to my patients, and I was running late for a meeting with the Dean. If you are like me, many days the practice of evidence-based medicine feels like the holey grail.
No, I haven’t become disillusioned with evidence-based medicine—just comfortable that there will always be a need for family physicians to translate the best evidence to our patients, as biased and value-laden as our recommendations may be.
What are your observations about actually practicing evidence-based medicine? Drop me an e-mail at jfp@fammed.uc.edu, and I will share the results in an upcoming issue.