Evidentia

I have studied health sciences at Oxford University

I would like to see the “care” put back in “health care”. Of course, as everyone knows, the real question is how. There have been many formulations of values along these lines, such as “patient-centred care”. My personal favourite, among such formulations, is narrative medicine, perhaps because I am a writer steeped in narratives.

It would be great if patients were treated as real persons, in a human dialogue, rather than just as abstractions, or as illustrations, on the micro level, of some medical phenomenon, on the macro level.

Doctor and patient (Photo by DaVita)

For example, I want to believe that science provides a more rational way of offering health-care, and yet I wonder whether this is not some sort of rational fantasy. I ran an international organization for six years, devoted to evidence-based medicine, to the value that patient care should involve the “conscientious, explicit and judicious use of the current best evidence.”

Moreover, I have studied evidence-based healthcare at Oxford University, and I am interested most of all in the meeting ground, if there is one, of narrative medicine and evidence-based medicine.

And yet there are days when I feel the evidence-based movement, far from being the remedy to so many woes in the practice of medicine, has become a religion of sorts, with its prophets, high priests, sacred texts, rituals and fervent devotees, who are really only talking among themselves.

In my experience, nurses are better listeners than physicians (Photo by Roger Aziz, for Dawson College, Montreal)

Can evidence-based medicine be adapted to the individual, in the way narrative medicine is?

I like the idea that medical decisions should be backed up by the best evidence available, and yet the definition of evidence often seems overly narrow. Does it include patient narratives? It should.

What if there is no real body of evidence, compelling or not, to justify a medical decision?

What if apparently solid evidence is derived from clinical trials undertaken by pharmaceutical companies, which may have deliberately skewed research outcomes, in order to promote their product, rather than give a fair view of how effective the product was in actual practice?

What if the physician’s understanding of evidence is very limited – for example, in the case where a physician continues to take decisions based on tradition, professional authority, prejudice, or some other factor?

What if professionals actually take decisions that are not shaped by Enlightenment values such as rationality, the rigorous analysis of the best evidence and the hierarchical ordering of levels of evidence?

What if the patient has a better idea what is “wrong”, but the physician simply won’t listen to the patient? In a blog on narrative medicine, elsewhere on this site, I remember quoting Dr. Rita Charon to the effect that in the average medical examination in the United States, the physician interrupted the patient after just 18 seconds.

What if the physician has an unscientific view of medical examinations? When I think of some of the physicians who have examined me, I am left wondering whether they did any medical studies at all. Seeing I was suffering from a herniated disc, one physician recommended that I drink lots of wine, go regularly to a Carpathian brothel and make love on all fours – he claimed this repeated movement would help reabsorb the hernia. Another physician examined me for all of two minutes, then prescribed a series of epidurals, as if I were about to give birth to a baby (quite the exploit for a man). A third physician, in reading the file his secretary had handed him, burst out laughing at my last name, and wailed in a Latin American accent, with tears dribbling down his face, that he simply couldn’t believe I had such a strange-looking last name. “My English name ‘Tombs’ actually means ‘son of Tom’,” I replied, “not ‘six feet under’.” He then launched into a long discourse on surrealistic literature. And by the way, I asked, what is your name? His reply: “Dr. Appletower.” I found his name very funny, but was too polite to say so.

The question of the limits of evidence-based medicine sometimes attracts attention. In a fascinating article in 1998, Ian Kerridge et al. raised issues on the ethics of evidence-based medicine. The article appeared in the British Medical Journal. According to them, “evidence-based medicine is unable to resolve competing claims of different interest groups; collecting sufficient satisfactory evidence raises problems – randomised controlled trials are only possible where there is genuine ‘therapeutic equipoise’; crude applications of results of clinical trials to individual care may disadvantage some patients; and allocating resources on the basis of evidence involves implicit value judgments and could imply that lack of evidence means lack of value.”

Behind many of these objections is one reality – diagnostic uncertainty

I suppose a fundamental idea in these objections is that the physician may be faced with diagnostic uncertainty – he or she simply may not know what is the matter with the patient. In cases of diagnostic uncertainty, applying an across-the-board rule, based on meta-analysis, randomised controlled trials and reams of statistics, may not help.

It is important to focus on the patient, and listen to the narrative – both the verbal narrative, and the narrative of the body. According to my experience, nurses are better listeners than physicians.

I hope to find answers as I continue my researches at Oxford University