Why is evidence-based medicine so difficult to follow?

By | October 3, 2017

As we continue to focus on value-based care, where quality and costs are extremely important, there has been an increasing emphasis on practicing evidenced-based medicine. Researchers are now beginning to collect data and evidence not only on clinical matters, but also on issues such as whether patient-centered medical homes truly work or if technology definitely lowers costs. As knowledge is accumulated on what works and what does not, increased vigilance using the information is necessary. Historically, in healthcare, even when proclaimed, evidence based practices are slow to be adopted.

There are numerous reasons why this avoidance of using such practices occurs. Study design is one. Frequently, a study is constructed from a purely scientific standpoint, yet the design does not fit everyday practice or reality. On the flip side, when we design trials that mimic reality, the science is challenging to translate due to the many variables. An additional major barrier occurs when outcome trials are published after a given practice has become mainstream. It is very hard to cease a given practice after it has become a habit, even if proven to not be beneficial. We underestimate the difficulty of stopping an activity once it has become embedded in actions.

As we consider the various trials around diet and exercise, they lack the foresight of implementation, which requires personal behavioral changes. This year is the 20th anniversary of a landmark trial showing the benefits of a certain type of diet and its relationship to hypertension and heart disease. Acceptance of this diet has been abysmal and of course the blame has fallen on the clinicians for not promoting the proven intervention. That could not be further from the truth. The bigger issue is that we have not studied how to implement the results from the individual’s perspective. We need to coordinate evidenced-based outcomes data with evidenced-based tools that demonstrate how to transform behavior. Whether gaming models, uncomplicated apps, or motivational interviewing, tying the mode of engagement and activation to the evidence-based data will become increasingly important if evidenced based practices are to be accepted by clinicians and those we serve.

We as clinicians are also given mixed messages by our subject matter experts. A prime example concerns statin therapy for primary prevention. Two different highly respected guideline bodies have reviewed the same evidence and published different recommendations.. These discrepancies create confusion both for the clinician and the patient. Usually when these schisms occur, we default to a place in our heads that basically says, “if the experts do not agree, I might as well do what I deem best, with or without evidence. “

As a true profession, we must rally around the concept of creating one set of guidelines and recommendation regardless of the issue. We let perfection get in the way of what should actually be the focus, improving adherence to evidence-based practices, both at the clinician and the patient level.