Evidence Based Medicine 1997Academic writings vs Community Standards - The Anatomy of a Medical Malpractice Action

Nine years ago an extensive review [1] concluded "there is a distressing distance between health care knowledge in general and the practices of individual physicians for most validated health care procedures." What impact have the early years of Evidence Based Medicine had on community standards of medical care?

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients[2]. The relatively fixed approach of a Leading Authority is now replaced by a slowly-evolving Consensus of experts, based on all the available data from well-designed research.

In 1972 it was shown that corticosteroid medication could safely reduce the risks of Perinatal Death and Respiratory Distress Syndrome in the infants of women likely to deliver early[3]. Twenty years later only a quarter of the mothers who could benefit were yet being offered and administered the drug[4]. We reported a year ago (Supplement to Medical Litigation News Volume 2, Issue 1) on other glaring examples of the gap between medical science and practice.

A recent study[5] measured Canadian physicians' compliance with Clinical Practice Guidelines of the Canadian Hypertension Society. Each basic investigation was missing from nearly half the medical records. In nearly half there was no record of lifestyle counselling, and advice was incomplete in the majority. Less than a third of the physicians followed recommendations for initial drug therapy. Unacceptable variations in practice may arise because of problems with physician education, peer review and autonomy[6]. Most practising physicians learned Authoritarian Medicine rather than Problem-based Medicine and consequently lack skills to evaluate new evidence and manage uncertainty.

PRACTICE POINT

Most practising physicians are ill-equipped to incorporate new evidence into clinical practice.


Both Continuing Medical Education and Performance Review remain largely informal and voluntary. Physicians may close ranks in the face of a claim for medical malpractice, but this colleagiality does not extend to peer support. In a US study, feedback about the practices of peers physicians had a minimal effect on the use of clinical procedures[7].

PRACTICE POINT

Evidence Based Medicine is in its infancy and will take a generation to usurp Authoritarian Medicine


Physician autonomy for investigation and treatment has previously been almost absolute, at least in office practice. Many traditional therapies which are known to be ineffective are also fairly harmless. Because individual patient outcome is a matter of probability, physicians are rarely confronted about clinical idiosyncrasies, bad judgments and disregard for new knowledge.

PRACTICE POINT

Community Standards continue to lag well behind Clinical Practice Guidlines.

Medical Malpractice litigation plays a valuable role in physician accountability.

Copyright 2008 Electronic Handbook of Legal Medicine