Technology, specifically Internet technology, has democratized medical practice by eliminating the traditional impediments to the flow of information. Suddenly, we are no longer constrained by what we happen to know or feel about a particular disease, condition, diagnostic tool, or treatment.
A few weeks ago, an article in Forbes asked, Do Facts Have a ½ Life? While arguing that knowledge in every discipline decays over time, the ½ life of medical knowledge was estimated to be 45 years, based on a hepatitis and cirrhosis study. Clearly, our medical knowledge is quickly and dramatically evolving.
Recently, 505 neurologists were surveyed regarding 4 antiepileptic drug (AED) announcements. Approximately 20% were not aware of 4 major drug safety risks: suicidality with newer AEDs, increased birth defect risks and impaired cognitive development from in utero divalproex exposure, and the requirement of haplotype screening in patients of Asian descent starting carbamazepine. Clearly, a knowledge gap exists.
It took decades for beta-blockers to go from contraindicated in patients with heart failure to the standard of practice it is today, in spite of evidence that treatment helped prolong survival. Clearly, medical practice adapts slower and less dramatically.
Why do we not keep up better?
Health care decisions have been and continue to be largely based on subjective determinants such as anecdotal evidence, experience, habit, ritual, instinct, and intuition. In short, the answer is that we are not consistently committed to making evidence-based decisions…yet.
The original model of evidence-based medicine went as follows: a clinical question arises at the point of care, the health care provider (1) conducts a literature search yielding multiple articles, (2) selects the best articles, (3)evaluates the research and determines its validity, and (4) decides what to do. Today, largely due to time and resource constraints, those authors acknowledge that this does not actually happen….yet.
Technology, specifically Internet technology, has democratized medical practice by eliminating the traditional impediments to the flow of information. Suddenly, we are no longer constrained by what we happen to know or feel about a particular disease, condition, diagnostic tool, or treatment. We now have the ability to take population data and apply them to an N of 1, for every patient we see, every time we see them. (And, by the way, so does the patient. With the Internet, the patient has the ability to learn from the same resources we do, which creates a new layer of accountability.)
Not everyone sees this as a positive. An essay by Arnold Relman, a 90-year-old former editor of the New England Journal of Medicine, laments that “attention to the masses of data generated by laboratory and imaging studies has shifted [our] focus away from the patient. Doctors now spend more time with their computers than at the bedside.”
I founded InpharmD precisely because I wanted to shift focus to the computer and data, but not at the expense of the patient. I believe that choosing between the two is a false dichotomy, because technology only helps health care providers make better decisions for the patient. I see a future in which each decision is based on an equal mixture of individual clinical expertise, the best external evidence, and patient values and expectations.
What do you think?