“Clinical Jazz”Harmonizing Clinical Experience

and Evidence-Based Medicine

David C. Slawson, MD

Allen F. Shaughnessy, PharmD

Lorne A. Becker, MD

Shaughnessy AF, Slawson DC, Becker L. Clinical jazz: Harmonizing clinical experience and evidence-based medicine. J Fam Pract 1998;47:425-8.

Objectives

• Perceived conflicts between EBM and

clinical experience

• Problems associated with relying solely on

clinical experience- self/experts

• Restructuring into harmony- “clinical jazz”

Wait a Minute! What About Clinical Experience?

“Clinical science and clinical expertise both have their

essential place in medicine. There is potential danger in

attempting to replace one by the other, in banning intuitive

knowledge from the realm of the “rational” and in placing

explicit, quantitative, calculating technique over implicit,

intuitive human understanding as the ideal for clinical

medical knowledge”Gordon DR. Clinical science and clinical expertise: changing boundaries between art and science in medicine. Lock M, Gordon DR, eds. Biomedicine Examined. 1988;Boston, Mass: Kluwer Academic Publishers, 257-95.

Clinical Experience

• The fertile ground from which ideas and

hypotheses grow

• Major conflict: Experience doesn’t jibe

with research-based evidence

Clinical Experience

• Not a source of valid POEMs

• Multiple validity problems

Clinical Experience - Validity

• Latest “bad experience” bias• “Out of sight, out of mind”

– “he would have told me if he was having problems”

• Nonrandom loss to follow up– Dissatisfied customers go elsewhere

• Inability to combine outcome data for multiple patients

Clinical Experience - Validity

• Small sample size

• “Stacking the deck”: Biased allocation to

treatment groups

• “Rose-colored glasses”: Biased

assessment of outcomes

“Reverse Gullibility”

• The story of Semmelweis

– 1847: hand washing decreased obstetric mortality

from 18% to 1.2%

– Virulent attacks lead to asylum commitment

• MDIs vs nebulizers, eye-patches, H. Pylori

(Barry Marshall), home glucose monitors, others

Experience: A problem of perception

• Moral: Clinical experience sometimes prevents seeing the right picture

• Now that you see it, can you try to not see it?

• Moral: Experience can result in ideas that are difficult to change 4

Do you see the Dalmatian in the picture?

www.optillusions.com

Perceptions are difficult to refute

Why is it so hard to

believe that this is

not a spiral but

actually a set of

concentric circles?

http://www.michaelbach.de/ot/ang_frazer/index.html

They really are!

Clinical Experience

Not really in competition with EBM

Combining EBM and Experience: “Clinical Jazz”

Structureplus

Improvisation

Clinical Jazz

Improvisation without structure =

cacophony

Structure without Improvisation=

tedium

Clinical Jazz

Remember “The Expert”

• Expert in diagnosis and procedures (clinical

experience)

• Not necessarily expert in therapeutics (EBM)

– Case series; LOE 4 at best

• The best expert (YODA) combines experience with

the evidence = Clinical Jazz

Valid POEMs Provide the Structure

Clinical Interventions Known to be Harmful

Clinical Interventions of Uncertain

Benefit

Clinical Interventions Known to be

Beneficial

gestational diabetes, bone densiometers, lung cancer screening

Advantages of Information Mastery

• A liberating structure

– Stable (little chance of ping-pongs)

– Simple rules (find the valid POEMs)

• Relatively non-restrictive

– There aren’t that many valid POEMs!

Clinical Improvisation - Opportunities

• Conditions with no valid POEMs

– e.g. Screening for lung cancer

• Conditions with multiple valid POEMs

– e.g. depression

Clinical Improvisation - Opportunities

• Patients whose characteristics differ from

those of patients included in research studies

• Implementation methods for valid POEMs

Clinical Improvisation - Potential Sources of Inspiration

• Clinical Experience

• Colleagues’ Ideas

• Local Experts & Consultants

• “Standard of Care”

• DOEs

• Others

Clinical Improvisation Not a Solo Activity

• Including the patient’s perspective

• Working with a clinical team

• Working with consultants

• Working with partners

“If you can’t listen, you can’t play jazz”

Wynton Marsalis

Using Clinical Experience to Develop Valid POEMs

• For Individual Patients

– N of 1 clinical trials

• For Groups of Patients

– outcomes-based research

1000 people in the community

750 will report an injury/illness

250 will seek care9 admitted

3 referred

1 university admission

Need for Outcomes Research in the Community

White KL, et al. N Engl J Med 1961;265:885-92

Valid POEMs“Outcomes-Based Research”

• Goal: Not to replace clinical judgment, but to give clinicians more information to base opinions and practices.

• “Primum non Nocere”

• “Dualism”- distinction between clinical experience and patient-oriented research is in error

Circle of Clinical Reasoning

Patient seenin practice

OutcomesResearch

ClinicalJudgment

Flaws in the Circle of Reasoning

• Fallacy of Division: What is true of the

whole must also be true of its parts– “Bell curve of clinical response”– Law of Diminishing Return, the “Keflex-

Reflex”

Flaws in the Circle of Reasoning

• Fallacy of Hasty Conclusion: What is true of

the parts must also be true of the whole

– Using evidence from clinical experience to

justify a general approach to all patients,

without applying the rigors of the scientific

method, may result in harm

Why is Medicine Here?• Goals of medicine:

– Relieve/prevent suffering– Maintain/provide hope– Prevent, treat, or cure disease

• The science of medicine:– knowing the best way to prevent, treat, or cure disease– EBM can address this aspect

• The art of medicine:– Determining, using intuition, experience, and judgment,

what patients need the most

• Clinical jazz = science + art

“Mundus Vult Decipi”- “The world wishes to be

deceived”People would rather be

deceived than have the truth create anxiety.

-Caleb Carr, “Killing Time”

“The only sure foundations of medicine are an intimate knowledge of the human body and observations on the effects of medicinal substances on that body”

-Thomas Jefferson

“America’s two greatest gifts to the world are jazz and Medline.”

--Richard Smith, BMJ 2001

The Yin and Yang of Medicine

• Start music

• Rigid enforcement of outcomes-based guidelines

just as misguided as foregoing results of patient-

oriented research

• The seeming opposites of medical practice,

clinical science and clinical experience, are

inseparable

• Structure with improvisation = true art

The Bottom Line

“We may not have all the right answers, but

we need to find and verify those that do

exist; for the rest, we need to ask the right

questions.”

“If we shadows have offended, Think but this, and all is mended, That you have but slumbered here, While these visions did appear. And this weak and idle theme, No more yielding but a dream, Gentles, do not reprehend. If you pardon, we will mend. . . . So good(bye) unto you all.”

William Shakespeare- A Midsummer Night’s Dream