1. “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.

2. Objectives Perceived conflicts between EBM and clinical experience Problems associated with relying solely on clinical experience- self/experts Restructuring into harmony- “clinical jazz”

3. 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.

4. Clinical Experience The fertile ground from which ideas and hypotheses grow Major conflict: Experience doesn’t jibe with research-based evidence

5. Clinical Experience Not a source of valid POEMs Multiple validity problems

6. 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

7. Clinical Experience - Validity Small sample size “Stacking the deck”: Biased allocation to treatment groups “Rose-colored glasses”: Biased assessment of outcomes

8. “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

9. 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

10. 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

11. They really are!

12. Clinical Experience Not really in competition with EBM

13. Combining EBM and Experience: “Clinical Jazz” Structure plus Improvisation

14. Clinical Jazz Improvisation without structure = cacophony

15. Structure without Improvisation= tedium Clinical Jazz

16. 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

18. 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

19. 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!

20. Clinical Improvisation - Opportunities Conditions with no valid POEMs –e.g. Screening for lung cancer Conditions with multiple valid POEMs –e.g. depression

21. Clinical Improvisation - Opportunities Patients whose characteristics differ from those of patients included in research studies Implementation methods for valid POEMs

22. Clinical Improvisation - Potential Sources of Inspiration Clinical Experience Colleagues’ Ideas Local Experts & Consultants “Standard of Care” DOEs Others

23. Clinical Improvisation Not a Solo Activity Including the patient’s perspective Working with a clinical team Working with consultants Working with partners

24. “If you can’t listen, you can’t play jazz” Wynton Marsalis

25. Using Clinical Experience to Develop Valid POEMs For Individual Patients –N of 1 clinical trials For Groups of Patients –outcomes-based research

26. 1000 people in the community 750 will report an injury/illness 250 will seek care 9 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

27. 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

28. Circle of Clinical Reasoning Patient seen in practice Outcomes Research Clinical Judgment

29. 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”

30. 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

31. 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

32. “Mundus Vult Decipi”- “The world wishes to be deceived” People would rather be deceived than have the truth create anxiety. -Caleb Carr, “Killing Time”

33. “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

34. “America’s two greatest gifts to the world are jazz and Medline.” --Richard Smith, BMJ 2001

35. 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

36. 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.”

37. “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