Best Evidence, `for whom the bell tolls`

Best evidence begs a number of questions: How do you define best? Best for whom?  Whose evidence? To whom does it apply? Where geographically and environmentally does it apply? Any slogan applied often enough and long enough becomes a cliché.  `Best evidence` applies to treatment, not to diagnosis. Without the right diagnosis, best evidence for treatment would seem irrelevant. That, however, is not the way we practice medicine today. Speed is everything. Diagnosis comes secondary to treatment, to the specialty at hand and secondary to the CMS requirement for tests and procedures – even for insurance reimbursement. Sorry, but the delivery of healthcare in the average hospital clinical complex has become more of a business than an application of the art, the science and the humanity of medicine.` Best evidence` runs the risk of becoming a tool for achieving the highest economic return for drug companies, insurance companies and hospitals. `Best evidence` can become a tool for subordinating the provider to administrative requirements, rather than limiting over treatment or the mistreatment for which it is intended.

For example: A 76yo WM retired truck driver seeks advice from a seemingly competent clinician in a large healthcare complex about his recurring bronchitis sometimes leading to pneumonia. He presently has only some loose rhonchi on physical exam, but does have a history of hayfever as a child and a smoking history of 20 pack-a-day-years, having stopped when he was 54. The clinician, limited for time, listens to the chest through his shirt, observes that the machine BP was normal taken by an aid, notes that the immunization history is out of date and that the patient has not had a sigmoidoscopy. The provider dutifully fills in the check marks on the hand-held computer-record ordering a sigmoidoscopy, immunizations, a video for smoking cessation and a TB skin test. The patient indicates that he has had BCG and has a mildly positive reaction. The provider then deletes the TB skin test and orders a CAT scan of the chest. The patient asks for something to stop the recurrent infections. The clinician then explains briefly and adds a video about misuse of antibiotics and the development of resistant strains. The CAT scan comes back questionable for a suspicious mass near the mediastinum. A repeat CAT is ordered for a month later. The repeat shows no change, maybe a bit better. Colonoscopy was negative; immunizations are updated.  All of the boxes on the electronic health record are checked appropriately fulfilling all of the tenants of `best evidence.` The clinician updates the problem list and expresses the opinion that it may be an old TB walled off in a lymph node requiring no further action, come back in a year. The patient ended up in the emergency room a month later with pneumonia.

Now in truth, the patient does have elevated blood pressure and a chronic allergic bronchitis together with aspiration, which has lead to recurrent bouts of debilitating bronchitis and pneumonia --- in this case, an emergency department admission a month later. A PCR for tuberculosis taken later as a requirement for a government job was negative for TB.

Later still, a kindly old internist practicing from his home does a complete history, system review and physical on our patient. He notes a Grade I murmur of aortic insufficiency at the cardiac base, indeed rhonchi and some wheezing in both lung fields, and an elevated BP. The physician places his patient on Lisinopril and defying the video’s newfound wisdom, adds prophylactic penicillin. The physician further steps outside of guidelines ordering basic lab including renal. His expectations of negative results are confirmed. A Holter monitor shows good BP control. A cardiac eco-scan shows good output. The internist asks the patient to return in one month for follow-up.

Not so exceptionally, this case illustrates a contrast between the urge to standardize care and the traditional physician driven care of the past. This is an actual case with some modifications for simplicity. If you were to view the regimented care as promoted by `best evidence`  from a cost basis or from an outcome basis, the kindly old internist wins every time. Why is that, when we know so much more today than we did and science is so advanced? Well, that is just the point. Science is advancing so fast that any standardized protocol becomes obsolete before it is printed. Furthermore, it applies to an arbitrary population not to an individual patient. It applies to an environment and location unrelated to the case at hand. Best evidence guidelines have the potential to serve the author of the guidelines rather than the patient for which they are intended. For example: a drug company for use of its patented high margin product, a hospital for its utilization of high priced procedures, an insurance company for its higher volume or a clinic for limiting its liability or the government attempting to  limit the cost of care -- all at the expense of the patient. Even more specifically `best evidence` may not apply to your patients own individual genetic makeup and his or her own proclivity for disease or reaction to treatment. Lastly, no treatment guideline can be valid in the face of missed or wrong diagnosis.