Heroes Not Zombies

I think there are many problems with what is known as “Evidence Based Medicine” (not least being the influence of vested interests such as Pharmaceutical companies on the production of “evidence”), and there is an interesting consideration of some of the issues in the BMJ. The paragraph on patients with multi-morbidity ie patients who are suffering from more than one chronic ailment at the same time caught my attention.

as the population ages and the prevalence of chronic degenerative diseases increases, the patient with a single condition that maps unproblematically to a single evidence based guideline is becoming a rarity. Even when primary studies were designed to include participants with multiple conditions, applying their findings to patients with particular comorbidities remains problematic. Multimorbidity (a single condition only in name) affects every person differently and seems to defy efforts to produce or apply objective scores, metrics, interventions, or guidelines.

Both the first and the last sentences of that paragraph really strike me.

“the patient with a single condition that maps unproblematically to a single evidence based guideline is becoming a rarity” – really? Who actually “maps unproblematically” to a guideline? No wonder they say it is becoming a rarity. Was it ever not so? Every single human being is unique. Each one of us has a unique genetic code, is born in a particular place at a particular time and lives a unique life, full of specific life events, challenges, difficulties, opportunities. Each of us tells an utterly unique life story when we sit with a doctor. That story is influenced by the past which is still active within us, and by our values, beliefs, preferences, our sensitivities, our coping strategies and our personal priorities. Biologically each of us is an open, dynamic system. We are continuously being influenced by, and are influencing, the environments in which we live. We never stay the same. At each stage of life we have different bodies and different minds from what we had before and we live in a world which previously never existed. If you’ve ever sat in a consulting room day after day, with patient after patient, you’d know that mapping individuals unproblematically onto guidelines is a fantasy.

“Multimorbidity (a single condition only in name) affects every person differently and seems to defy efforts to produce or apply objective scores, metrics, interventions, or guidelines” Even the most diehard statistics fans know this one. The more conditions a person has, the more difficult it is to predict how things are going to go, which treatments are going to work well for them, and which are going to do them harm. It’s worth remembering that there is no evidence for polypharmacy. Anywhere. The truth is individuals are so unique that even those with a single diagnosis will not experience the same course of the disease, will not get the same results from the same treatments, and will not experience the same particular side-effects or harms. The problems which are highlighted in the situation of multimorbidity still exist in situations where a single disease has been diagnosed. The problems multiply for sure, but there isn’t a situation where they don’t exist.

Sometimes I think there is only one “best” evidence base when treating a person, and that is the ongoing, careful, humble, consideration and understanding of what this person is experiencing. Whatever treatment is given, only this patient’s unique experience is the final arbiter of its usefulness. Not some statistics-oriented guideline produced by a non-clinician who will never have any interaction with this patient.