In Defense of Eminence-Based Medicine

An internal memo to the members of the Society for Truculent Underappreciated Practitioners of Inpatient Doctoring

To arms, august compatriots! Our very way of life is threatened by the hordes of barbarians at our gates. Armed not with pitchforks and torches, but with Cochrane reviews, “multicenter randomized controlled trials,” the interwebs, and “tablet computers,” they besiege our traditions and values and threaten our place in the hierarchy of medicine. In no uncertain terms, they want to remove us from our place of reverence, from our position of respect, and replace us with guidelines, pathways, and protocols. To do nothing is to perish. We must stand together and fight this tide or be swept away in the tidal wave of journals and statistical analyses buffeting our land. Join or die!

For generations, we have preserved our careers and medicine itself by strictly honoring a system based on “eminence-based medicine” or “EBM.” This is the practice of making the same sound decisions with increasing confidence over an impressive number of years (some of the barbarians have even mocked and disregarded this definition, co-opting “EBM” for their own purposes and replacing “sound decisions” in the true definition with “mistakes.” The nerve). Upon what else does our hallowed practice rest than this? Imagine the disorder and chaos if students or lowly interns were allowed to question the decisions we, the wise practitioners, make. I have seen enough patients with pyaemia or blood rot in my time to know how to treat them, thank you very much. I don’t need some unwashed whelp of a trainee waiving a New England Journal article in my face, saying I am giving too much or too little fluid to the patient. I once took care of a septic patient and gave them absolutely no fluid, and they survived. So much for the so-called “evidence.” There is no amount of evidence that can replace intuition and sound clinical acumen. As many of you likely can affirm, a true clinician can almost feel the right thing to do. A challenge to this as the basis of medicine is akin to advocating a change from the “art of medicine” to the “science of medicine.” Blasphemy.

I am sure each of you have experienced some form of this assault. In fact, the medical literature today is full of direct attacks on eminence [1]. The threat is becoming more acute by the day as even the lowliest trainee has access to the entire world’s archive of medical literature in their pocket. To survive, we must arm ourselves and fight back. We must have at the ready an armamentarium of weapons and tools to stem the tide and turn back the latter-day Visigoths who fling their regression analyses, critical appraisal tools, and “levels of evidence” at our battlements. What follows is an attempt to codify some of those tools and to help all of our eminent practitioners to soldier on in the fight.

1. “Harrumph and eye roll”: When confronted with what seems like sound evidence that counters the way you have treated something for many years, simply roll your eyes in a dramatic way, make a “harrumph”-ing sound quite loudly, and say something like, “Well, balanced salt solutions may make physiologic sense, but normal saline has worked for me for many years.” The italics imply rhetorically stressing the avenue of attack chosen by the challenger and throwing it back at them in a mocking or sarcastic way and then reminding them of how much more experience you have than they do. While seemingly basic and perhaps puerile, it is astounding how effective this technique can be. But the “harrumph” you throw in must be emphatic and said with conviction. This technique rests entirely on how invested in it you can be.
2. “My specific patient is different”: These evidence cultists always want to assume that their numbers and ratios always apply to everyone. It is relatively simple to find some minor clinical difference between the particular patient under discussion and the participants in whatever trial your foe is citing. For example, when challenged on your management of a ventilated patient, you can say, “Well, in the ARDSnet trial, they didn’t specifically analyze the subgroup of patients with influenza and CHF, did they?” or “the secretions of influenza in a patient with CHF are clearly unique.” Defenses like this usually put them on their heels as they will either have to go back to the trial itself to check or admit that they are not quite sure.
3. “In my experience . . . ”: No matter how much evidence is presented, it is always possible to unearth the musty contents of your own shadowy past. Ill-defined and utterly unverifiable, your “experiences” with individual patients, if described colorfully and in detail, can easily counter dry references to impersonal literature reports. It can also refute arguments of physiology. If you have seen something before, your eyewitness account is much more reliable than some “deep understanding of physiologic principles.”
4. Question the quality of the training of the evidence hound. No matter what they say or how many “facts” they can cite, one can almost always cast aspersions on their training in some way. “When I was at Harvard…” is a near-perfect oratory introduction to asserting your proper place.
5. Point out some minute problem in the design of the study being quoted. Although somewhat unsavory, as it may require stooping to the tactics employed by our attackers, it is always possible to take issue with some aspect of any given study. “I can’t believe they used a Kolmogorov–Smirnov test when they clearly should have used Pitman’s permutation test. The results of this study are suspect to say the least.” This should require quite a bit of investigation by the whelp, by which time you should be safely ensconced in the doctor’s lounge.
6. Cite a report that supports your viewpoint. Again somewhat unsavory, but even when someone states that three RCTs have shown that a certain treatment is “clearly” superior to how you have been doing things, you can almost always cite a trial that does support you (“while it is interesting that those investigations show that digitalis is not effective in heart failure in general, Jones et al. showed that it reduced readmission rates in the Congo when given to patients with CHF due to parasitic disease . . . ”). Always remember to end the discussion with “so clearly the jury is still out on this subject.”
7. Lean heavily on the axiom that “lack of evidence of efficacy is not evidence of lack of efficacy.” This is very powerful and can be carried quite far. No matter how many trials show that a treatment doesn’t work, this single sentence irrefutably ends discussion in most cases.
8. Utilize physiologic smoke screens. Delve deeply into your medical school texts, and have at the ready in-depth discussions of biochemical and physiologic pathways. Learn to describe how they interact in such detail that no one can really follow what you are getting at, but throw in enough polysyllabic words and pathway intermediates so that you are untouchable, no matter how much evidence is tossed around. In today’s world, most trainees’ education in biochemistry, physiology, and anatomy has been short-shrifted to a stunning degree by the addition of silly classes on biostatistics, ethics, diversity, professionalism, and other such drivel, so you can be generally assured they will have no comeback for this defense.
9. “Cookbook medicine”: Throw out derogatory terms such as “cookbook medicine” and wax nostalgic for the times when doctors truly “thought” about their patients and cared about them. This is particularly effective when you can question the humanity of your foe, asserting that “statistics and numbers can never substitute for the human being in the bed in front of you. You would do well to remember that.” Follow up with a moving patient story where your attention to detail and the history of that individual patient made all the difference and where your diagnosis and treatment plan flew in the face of the naysayers, and you are safe.
10. Parachutes. Go nuclear, and question evidence itself. This is obviously high-risk but can be very effective. Building on the excellent article utilizing the example of the parachute as a preventative treatment for high-altitude falls that has never been verified in a RCT (despite the fact that there are case reports of parachute-less high-altitude falls resulting in subject survival), make the point that medicine is more than evidence [2]. Rub their nose in the fact that true doctors can see the value in treatments that are of “obvious” value, even without evidence.
11. Question the work ethic or integrity of the evidence bearer. No matter what they say, find some fault with their daily routine, or pre-rounding attention to detail, or accuracy of information they provided about the patient. Proceed to vociferously making sure that everyone in earshot is aware of what is happening, point out their deficiencies, and intimate that anything they say is suspect.
12. Trump them. If all else fails, utilize the debate technique made so famous by the current presidential candidate, Donald Trump. Previously known as “vehemence-based medicine,” simply raising the volume of your opinion and employing an attitude that your opponent is a complete and utter moron will shut down any opposition [3]. With this technique, if employed correctly, any amount of logic or number of facts will wilt in the glare of your intensity and scorn.
13. Eloquence- and elegance-based argumentation. Much to the chagrin of the attackers, it is still well-accepted that “brilliant oratory,…a year round suntan, [and/or] a silk suit” can overwhelm the senses of most of the sandal-wearing hippies who worship at the altar of evidence [3]. Keep your style impressive and tighten your bow ties!

Be strong, my brothers and sisters! While some furtive attempts have been made to fight back and harness the power of our eminence, we are clearly in danger [4]. In the face of this growing threat, our ability to wield our eminence may falter. We hope that the techniques described herein will serve you well in our struggle. Let not these heathens question our place or sacred way of life. Stand tall, and continue to be the face of “EBM.”

Brigham C. Willis, MD, M.Ed.

+ posts

Brigham C. Willis, MD, MEd, completed his undergraduate studies at UCLA, graduated from UCSF School of Medicine, completed his residency at Children’s Hospital and Research Center at Oakland, and finished his training in a fellowship in pediatric critical care medicine at Children’s Hospital Los Angeles. He is now an associate professor in the Department of Child Health and a staff physician in the cardiac intensive care unit at Phoenix Children’s Hospital. Dr. Willis has also maintained a strong interest in medical education throughout his career, recently completing a Master of Education degree in higher education at Arizona State University. Prior to coming to Phoenix, he served as associate fellowship director for pediatric critical care medicine at the University of Texas Southwestern and was active in medical student and resident education. He has been teaching at the college since 2008, lecturing and facilitating case-based instruction (CBI) sessions in cardiac, renal, and pulmonary physiology as well as mentoring multiple students for their scholarly projects. Of note, he was selected as a master educator by the Class of 2015, the highest teaching honor bestowed at the college. He served as director of electives from 2011-2012, was a student advisor from 2013-2015 and is currently associate program director for scholarly activity in the Pediatric Critical Care Medicine Fellowship Program. Dr. Willis is excited to serve in his new role directing the fourth-year critical care Selective.

This author does not have any more posts.