EVIDENCE-BASED MEDICINE
 

 

Authoritarian medicine is being overthrown by Evidence-Based Medicine, which is barely 5 years old. A major shift in Personal Injury and Medical Negligence legal practice will likely follow shortly.

Since the 1960s, increasing numbers of physicians have demanded rigorous experimental proof that specific medical interventions are effective[1a]. Randomised, controlled clinical trials have become the gold standard.

Entrenched Traditions

Routine medical treatment and management have lagged behind empirical knowledge. Much conventional medical wisdom has no basis in medical research[2], including recommendations made by recognised authorities in leading journals[3], [4a].

Formerly, standards of clinical practice persisted long after accumulated evidence had discredited traditional treatments[5a].

Physicians continued to prescribe Diethylstilbestrol (DES) in pregnancy, despite considerable mid-1950s evidence refuting its supposed effectiveness. Only when association with cancer of the vagina in daughters appeared in the early 1970s did clinical practice change[6], [7].

Leaders in the field have continued to promote ineffective treatment and disregard effective therapies[5b].

For 30 years, authorities recommended calcium-channel blockers and antiarrhythmic medications for heart-attacks, even though there was no proof they worked, and there was evidence they were harmful. Meanwhile, the same experts failed to advise thrombolytic therapy and aspirin, even though research had shown they were effective treatments[4b].

Common complications may be documented in the medical research literature but are still ignored by practising physicians. Judgments for medical negligence plaintiffs may be the catalyst for changes in medical standards.

Months of postoperative backache will trouble up to a fifth of patients undergoing general anesthesia and major surgery, and will disable some[8]. A simple inflatable lumbar support during surgery prevents this complication, particularly for those with a history of backache or undergoing procedures lasting more than 40 minutes[9], [10].

Evidence-Based Testimony

A few teaching centres have made the paradigm-shift.

The Department of Obstetrics, Gynecology, and Reproductive Sciences at San Francisco General Hospital, University of California, San Francisco is 3 years into Evidence-Based teaching. Problem-solving seminars have replaced traditional lectures, and clinical decisions use formal rules of evidence[11].

Medical litigation lawyers will increasingly depend on Evidence-Based Practice Guidelines[12], [13], [14] , the clinician's practical answer to information overload. Some organisations are publishing structured summaries, describing how the recommendations were derived[15]. Practice guidelines can provide objective criteria for the medicolegal assessment of standard of care.

Medical Authorities unreliable PI witnesses

Academic physicians with some knowledge in a given area, and particularly those with limited factual background, are better than "the experts" in the field at reviewing the research evidence, and they reach greater consensus about the conclusions which should be drawn. An "expert's" personal biases and memorable clinical experiences may distort a more complete and balanced view of causation and prognosis.

Traditionally, the courts have accepted the personal experience of credible expert witnesses and the opinions of recognised Authorities, but the climate of medical opinion will increasingly favour instead the conclusions of well-designed clinical research[16], [4c], [1b].

Fiscal Constraints

Consumer and insurer demand for cost-containment increasingly influence standards of medical practice.

Routine Diagnostic Ultra Sound (DUS) in early pregnancy leads to earlier diagnosis of multiple pregnancy, and reduces the frequency of induction of labour for post-term pregnancy ("postmaturity"). There is no convincing evidence the practice is harmful, except to health-care costs[17].

Evidence-based Medicine will, conversely, cut costs by supporting the abandonment of wasteful screening procedures such as microscopic examination of urine[18] and blood Erythrocyte Sedimentation Rate[19].

Copyright 2009 Electronic Handbook of Legal Medicine