Feb 13, 2015 — Dr. Howard Bauchner, editor-in-chief of JAMA, comments on new trends in evidence-based medicine. He notes that randomized controlled studies aren’t always king, even though they’re the most common. Patients want more of a say in the type of treatment they receive, particularly for certain types of cancer and end-of-life care. Dr. Bauchner provides insight on these issues and more.

Interview

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Willard: I'm Willard Dere at the University of Utah, professor of medicine. And we're joined here today by Dr. Howard Bauchner who is Editor and Chief of The Journal of the American Medical Association. Could you comment on evidence based medicine? Where we are right now and the role that it plays for our future physicians, or our current physicians.

Dr. Bauchner: I think there's a number of evolving issues in evidence based medicine that will be helpful. It's something I'm particularly familiar with. But I think there are three or four issues that are evolving. First, the hierarchy. The top of the hierarchy has always been randomized trials. Some people put meta-analysis above RCTs. So for example, John Ioannidis would argue five or six smaller studies saying the same thing may be more important than a single large RCT. I think one can debate that. We do know that propensity scoring instrumental variables do help to control for known confounding variable. The relentless issue and struggle will be then, an observational studies unknown confounding simply cannot be controlled for.
On the other hand, only about 20 or 25% of medical decisions can be made based upon RCTs. So that means there's three-quarters of the decisions that I have to make every day in which I have to make some recommendations based on observational data. So I think people have reconciled that more, and more, and more recently.

The other evolving trends is, I think, we have to be very careful in medicine around quality indicators or how we prompt physicians. Those indicators should only be based on the highest level of evidence. So for example, if you look at the "Choosing Wisely" campaign, we had a research letter. I think the first 40 or 45 items that were listed by different professional societies for physicians to take great care about with respect to prescribing, treating, or testing. Three-quarters of them really were based upon a discussion between a physician and a patient. There wasn't strong evidence to recommend doing A or doing B. And so the types of strong recommendations should only be driven when there's high quality evidence.

The other thing that now factors into the decision is that physicians aren't nearly as autocratic, or shouldn't be as nearly autocratic as perhaps they were 20 or 30 years ago. So patients want much more of a say in decisions that affect their lives. This is particularly true around end of life care or chronic care. Around acute care, I still believe that most patients are comfortable with physicians making the decisions. And so there, it's a much more complicated issue.

And this has played out in three specific areas. Women's decisions about what type of treatment they get for breast cancer. This is really a discussion between a physician and a patient. What treatment men get for prostate cancer. The data are still uncertain in a number of areas. And the last is an issue that has emerged just over the last two years. And that was with the new recommendations around statins. And they've been debated hotly around the world. But Victor Montori, who really focuses a lot on patient centered care, gave three examples in JAMA, of patients who based on the guidelines would qualify for the Staten, but because the evidence wasn't so strong, if you talk to the patient, two of them chose not to take statins. And one chose to take statins.
So I think the other evolving piece around evidence based medicine, is when the data are less robust, then it really requires a discussion between a care provider or a physician and a patient to reach a reasonable decision.

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