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When we can’t base it on evidence we just ask Bob

All medicine has significant areas of uncertainty, be the most informed you can be, and know where to look for good research.

I attended grand rounds for OB/GYNs at a major teaching hospital last year to see a friend speak. Before her lecture began, the head resident did a little house keeping. He mentioned that they were tracking hand washing differently, and holiday schedules had changed—then he said something that really surprised me.

He said, “Oh, and the bladder flap procedure you do in cesarean sections, well that is not necessary. Turns out that that just got started and there is no medical reason for it.”

What?!? They have been incising and separating women’s bladders because someone thought it was a good idea? No evidence needed, just a theory?

That got me thinking...I mean, I practice integrative and functional medicine, and conventional medicine often portrays it as unfounded because it is not evidence-based medicine. Then I started noticing the lack of evidence in conventional medicine everywhere.

First, there was the big controversy over the colonoscopy versus sigmoidoscopy. Turns out doctors started doing colonoscopies because one doctor said it was probably a better idea because you get to see the whole intestine, don’t worry that risks and costs go up, or that no comparison studies had been done. When studies finally came out saying that sigmoidoscopies are just as good, with lower costs and risks, conventional doctors said we need more than one study. Then two more studies came out. Now it’s hard because they are all invested in colonoscopies, changing could mean a big loss of revenue.

That’s just one example.

Then, an article came out in the Archives of Internal Medicine, Analysis of Overall Evidence behind Infectious Disease Society of America’s Practice Guidelines, by Lee, D. (vol. 171, no. 1, January, 11, 2011). The study analyzed the strength of recommendations and overall quality of evidence behind 41 Infectious Diseases Society of America (IDSA) guidelines. And? ... more than half (55%) of the recommendations were based on Level III evidence. Level III is based on expert opinion only and is the lowest possible category.

You’re not practicing evidence-based medicine if you are using Level III evidence! Granted it is the opinions of respected authorities based on clinical experience, studies, and reports, but it is still just that, an opinion.

So the point of my rant?

All medicine has significant areas of uncertainty, be the most informed you can be, and know where to look for good research. Sometimes practice-based, with good biochemical support theories, is all you have. I think over the next 10 years more evidence and data are going to be compiled to strengthen clinical decisions.

That’s a win for everybody. ~ Dr. Elizabeth Redmond

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