by Lindsey Wimmer, RN, MSN, CPNP, CPLC
Evidence-based medicine and patient-centered care are two very popular buzz words in health care, but they often don’t make sense to the general public and can be conflicting principles. I attended a lecture last week by Dr. Sixto F. Guiang on this very topic at the annual meeting of the Minnesota Perinatal Organization. He did a wonderful job of explaining to the audience how and why evidence-based medicine is used. But, I also appreciated his acknowledgement that it is critical that common sense also comes into play.
Most physicians are very scientific, analytical people. They like concepts to be proven in black and white and have a clear explanation. I admit that I am one of these people! Unfortunately, life doesn’t always follow the rules – especially in medicine.
The concept of evidence-based medicine is that decisions made and interventions employed should be proven to be beneficial without undue harm. It also considers the frequency of false-positive or false-negative results, emotional distress on the patient, and cost-benefit ratio. To make these decisions, we utilize research studies that come in varying degrees of rigor and quality. By definition, research is not perfect, but it is often the best we can do without placing humans at unreasonable risk or breaking rules of ethics. We utilize statistical applications of power, statistical significance, confidence intervals, odds ratios, and more. After years of work and analysis on many studies, health care leaders do their best to interpret the findings and make suggestions that are used by health professionals.
Protocols and guidelines developed from this work helps providers make decisions, offer recommendations to families, and be confident in their practice. It serves to keep providers from being swayed by a single study or ancedotal stories. It helps insurance companies know what treatments are reasonable and cost-effective in an effort to reduce costs related to unnecessary or unproven methods.
The drawback is that research isn’t perfect.
There are often outliers that don’t seem significant – until YOU are the outlier.
That’s when the reality hits that we are working with people who have families that love them and lifetimes of potential. This is where the principle of patient-centered care enters the picture.
Health professionals may be the ones with years of study and experience, but the patients are the individuals who must live with the effects of decisions. This is why we also consider clinical significance – what type of an impact the decisions have on the patient and family regardless of if the studies show it to be statistically significant or not. Patient-centered care requires providers to respect individual beliefs, desires, needs, and values. It is the idea that the patient can determine if recommended care is appropriate for them. Families today are more educated, more empowered, and have more resources than ever before when making medical decisions. When the science directs us to a protocol or decision that is desired by the patient, the system works beautifully. But, what do we do when the science and the patient’s wishes differ?
There are many examples of this throughout medicine, including in obstetrics. The 39-week rule, bed rest, stripping membranes, pain control during labor, prenatal testing and monitoring, pregnancy after loss care, and more are issues where the patient and provider may or may not agree, and the science may or may not support either side.
This is the true ‘art’ of medicine. Depending on the situation or your personality, this gray zone can be frustrating or empowering. As with any skill, there are some providers who excel at this aspect and some who struggle. There are also patients who appreciate or are challenged by the lack of easy answers.
It may appear that these two guiding principles of health care work against each other. But, they don’t have to.
I urge every health professional to use evidence-based medicine as a tool for patient-centered care. It is not the one and only answer, but it helps us make decisions WITH our patients. Each decision should be a dialogue between the patient/family and the health professionals. The medical evidence is part of what the providers bring to this conversation. So is their experience. The families bring to the table their own values, experiences, cost-benefit ratios, and needs. The patient-provider relationship is a partnership with equal amounts of respect. The outcome will probably not look the same in every situation – and that is not a bad thing. Every patient is different, so it is appropriate that their decisions and outcomes may also be different.
The elephant in the room, especially in the United States, is that the guidelines and evidence-based practice help protect the health professionals from litigation. If they follow the protocol, their liability is reduced. This is fueled by our desire for black and white answers. However, most patients are not inclined to pursue legal recourse for unexpected outcomes if they were part of the decision-making process and felt that their opinions were heard and respected. Instead of teaching our new health professionals that the protocols and guidelines will keep them out of court, we should help them understand that listening to and partnering with their patients will keep them out of court AND lead to more positive outcomes (as the family defines them!).
Instead of feeling limited or protected by the concepts of evidence-based medicine and patient-centered care, we all need to embrace what they can bring to the table. This is what Dr. Guiang was referring to when talking about using ‘common sense’. These concepts should be well-understood and respected by health professionals and patients because they are part of the large and small conversations in health care today. And they can make significant differences in all of our lives.