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Balancing the Patient Experience with Evidence-Based Medicine

Patient Getting an MRIRecently, Dr. Peter Kramer published an intriguing, well-written, but poorly reasoned and potentially dangerous “thought piece” in the New York Times. His article, “Why Doctors Need Stories,” contains several logical flaws and erroneous arguments, but the overarching concept is a classic “straw man” argument.

He creates a false and highly misleading notion of what “evidence-based medicine” (EBM) is and then proceeds with a screed against EBM in order to extol the virtue of the anecdote. This sort of argument works particularly well when the reader has little or no knowledge of the term being misrepresented, so I expect it’s been quite effective even with the generally well-informed Times readership, who wouldn’t be expected to know what EBM is.

Understanding Evidence-Based Medicine
So let’s start with what Kramer says about EBM in his piece. He notes that his preferred approach, “giving weight to the combination of doctors’ experience and biological plausibility, stands somewhat in conflict with the principles of evidence-based medicine. The [EBM] movement’s manifesto, published in the Journal of the American Medical Association in 1992, proclaimed a new era that would see near-exclusive reliance on systematic clinical research—the direct assessment of treatments in patients.”

Kramer allows himself some wiggle room by saying “somewhat” and adding “near” to “exclusive reliance,” but the point is crystal clear: these doctrinaire EBMers, manifesto in hand, are preventing us warm and caring docs from talking with our patients, forcing us into a mindless and soulless practice of cookbook medicine wherein we follow protocols and algorithms and ignore the heartfelt pleas of our patients seeking succor and support. If only doctors were trained to listen to their patients, to understand the power of stories, we’d all be happier and healthier.

But he’s creating a false premise to explode. First, what is this “manifesto”? Since Kramer refers to something published in the Journal of the American Medical Association (JAMA) in 1992, I presume he means “Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine.” This, and the series of “Users’ Guides to the Medical Literature” subsequently published in JAMA (then in book form and now on the Web), can hardly be considered “manifestos” (at least, not as the sort of doctrinaire rulebooks the word usually implies). (Helpful note: I keep my copy of Marx on a different shelf of my bookcase from the one where I keep my “Users’ Guides” to avoid just such confusion.)

Looking at this “manifesto,” I found it almost amusing to see what the authors wrote 22 years ago in describing how wrong-headed doctors make false arguments against EBM: “Misinterpretation 1.—Evidence-based medicine ignores clinical experience and clinical intuition.” (Straw man, anyone?)

Now let’s look at what EBM really is. As defined nearly 20 years ago by David Sackett, one of the founders of this discipline: “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

Patients’ stories—case histories—are evidence. All of the EBM “manifestos” acknowledge that, and case reports have always been part of the EBM landscape. (Indeed, my own first publication was a case report.) But there is an important caveat: case studies (and patients’ stories) are weaker evidence than carefully designed and conducted (and appropriately interpreted) research studies. There is a hierarchy of evidence, and case reports are at the lowest level of that hierarchy. There are excellent reasons for this, but that’s a separate discussion.

The Role of Narrative Medicine
The persuasive power of the piece is enhanced by the image of the lone wolf crying out for justice in an unjust world: “I have long felt isolated in this position, embracing stories.” Nice image, but a quick look at the world around him would have shown Dr. Kramer that he is not alone. Indeed, the growth of what has come to be known as “narrative medicine” began in the 1990s, paralleling (and perhaps partly in response to) the development of EBM. Now, in my opinion, the valuing of stories over evidence is highly dangerous, and if you’re looking for acolytes rather than scientists, you’re more likely to find them preaching narrative medicine than practicing EBM. . . . But look at me: Kramer has got me mirroring his false dichotomy.

Any good doctor knows that both listening to stories (in the context of clinical experience and good judgment) and applying research studies (judiciously and competently) are required to practice medicine. Caring for patients using one without the other is a fool’s errand. (And by the way: my medical school, Albert Einstein College of Medicine, like most medical schools, puts a lot of effort into teaching communication skills—including through “narrative medicine”—to its students.) Blending the two approaches effectively and seamlessly isn’t easy, but the goal of medical education—and doctoring—is to strike the right balance.

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