CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Ori Ben-Yehuda, MD, FACC*
* Division of Cardiology, University of California, San Diego, UCSD Medical Center, 200 West Arbor Drive, San Diego, California 92103 (Email: obenyehuda{at}ucsd.edu).
Dr. Karthikeyan, in an impassioned response to the study by Pereira et al. (1) and my accompanying editorial (2), which highlighted the role of clinical judgment, states that detractors of evidence-based medicine "imbue ‘clinical judgment’ with an aura, which barely falls short of the divine." The message in the editorial, as well as in the original report, was not intended to either "detract" from the appropriate role of evidence-based medicine garnered through sound scientific research or to claim any magical powers for clinical judgment. Rather, the main point, supported by the findings of the study by Pereira et al. (1), is that the complexity of the clinical decision process as well as the uniqueness of each individual patient may not always be adequately captured in our evidenced-based criteria.
Dr. Karthikeyan rightly points out that some of the reasons the physicians chose one treatment over the other were objective findings on the angiogram. Yet these physicians were better able to risk-stratify the patients despite the a priori "equivalence" of the findings based on the entry criteria of the trial.
No amount of clinical trial data can ever capture the almost infinite variables involved in the complex biology of health and disease. In addition, the somewhat arbitrary cutoffs employed in data analysis add additional limitations. Take as an example the findings from the SHOCK (SHould we revascularize Occluded Coronaries for cardiogenic shocK) trial (3) that patients over the age of 75 did not benefit from revascularization. Taken to its absurd limit, would the thoughtful clinician withhold revascularization from the robust patient who is 76 years old and, conversely, prescribe it for the frail 74-year-old with co-morbidities?
Few would argue with the statement that evidence-based medicine has improved clinical care. We should be careful, however, to borrow from Dr. Karthikeyan’s own terminology, from ascribing "divine" powers to evidence-based medicine and guidelines. The limitations of our knowledge base must be acknowledged, as is the contribution of physician experience and judgment, particularly in individual patients. We should also use scientific methods, as admirably done by Pereira et al. (1), to evaluate evidence-based medicine itself, and to help improve our clinical decision-making process.
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References
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- 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]
- Ben-Yehuda O. Physician judgment in cardiology: the art of medicine lives on J Am Coll Cardiol 2006;48:954-955.[Free Full Text]
- Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock N Engl J Med 1999;341:625-634.[Abstract/Free Full Text]
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