CORRESPONDENCE: LETTER TO THE EDITOR
Evidence-Based Medicine and Clinical Judgment: An Imaginary Divide
Ganesan Karthikeyan, MD, DM*
* Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi–110029, India (Email: karthik2010{at}gmail.com).
The study by Pereira et al. (1) and the accompanying commentary by Ben-Yehuda (2) once again bring to the fore some often-raised arguments against evidence-based medicine. Detractors of evidence-based medicine tend to imbue "clinical judgment" with an aura, which barely falls short of the divine, by attributing intangible powers to clinicians. This view of clinical judgment is more about the clinician than about judgment. In reality, individuals, clinicians, or otherwise, are swayed more by anecdotal experience (3); as a result, they are more prone to systematic errors while making judgments under situations of uncertainty (4). Evidence from clinical trials, if anything, adds objectivity, reduces bias, and refines a clinician’s ability to make decisions.
In the study by Pereira et al. (1), the participating clinicians were not in agreement with the random allocation in more than half the patients. As pointed out by the investigators, the different prevalence of 3-vessel disease and the complexity of lesions were primarily responsible for this situation. Stated simply, the clinicians were (justifiably) reluctant to send patients with complex lesions and 3-vessel disease for angioplasty, because they were aware of the data that these patients would not have the best results with angioplasty. Numbers permitting, subgroup analysis of the trial would probably bear out these clinicians’ concerns. Therefore, what has been somewhat mystically termed "clinical judgment" is nothing but the correct interpretation of available data by discerning cardiologists.
It is important for the scientific community to recognize that there is in fact no real disconnect between evidence-based medicine and an individual clinician’s judgment. Gone are the days when a few towering experts drew on personal experience to make clinical decisions. Good clinical judgment in the present day has evolved into the clinician’s ability to appropriately interpret and incorporate available evidence in the day-to-day management of patients. Of course, some clinicians will be better at this than others!
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1. Pereira AC, Lopes NHM, Soares PR, et al. Clinical judgment and treatment options in stable multivessel coronary artery disease: results from the one-year follow-up of the MASS II (Medicine, Angioplasty, or Surgery Study II) J Am Coll Cardiol 2006;48:948-953.[Abstract/Free Full Text]2. Ben-Yehuda O. Physician judgment in cardiology: the art of medicine lives on J Am Coll Cardiol 2006;48:954-955.[Free Full Text] 3. Newman TB. The power of stories over statistics BMJ 2003;327:1424-1427.[Free Full Text] 4. Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases Science 1974;185:1124-1131.[Abstract/Free Full Text]
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