In Defense of Eminence-Based Medicine

An internal memo to the members of the Society for Truculent Underappreciated Practitioners of Inpatient Doctoring

Brigham C. Willis, MD, MEd

Department of Medical Education and Division of Cardiovascular Intensive Care
Phoenix Children's Hospital
Phoenix, AZ USA

To arms, august compatriots! Our very way of life is threatened by the hordes of barbarians at our gates. Armed not with pitchforks and torches, but with Cochrane reviews, “multicenter randomized controlled trials”, the Interwebs, and “tablet computers”, they besiege our traditions and values, and threaten our place in the hierarchy of medicine. In no uncertain terms, they want to remove us from our place of reverence, from our position of respect, and replace us with guidelines, pathways, and protocols. To do nothing is to perish. We must stand together, and fight this tide, or be swept away in the tidal wave of journals and statistical analyses buffeting our land. Join or Die!

For generations, we have preserved our careers and medicine itself by strictly honoring a system based on “eminence-based medicine” or “EBM”. This is the practice of making the same sound decisions with increasing confidence over an impressive number of years (some of the barbarians have even mocked and disregarded this definition, co-opting “EBM” for their own purposes and replacing “sound decisions” in the true definition with “mistakes”. The nerve.) Upon what else does our hallowed practice rest than this? Imagine the disorder and chaos if students or lowly interns were allowed to question the decisions we, the wise practitioners, make. I have seen enough patents with pyemia or blood rot in my time to know how to treat them, thank you very much. I don’t need some unwashed whelp of a trainee waiving a New England Journal article in my face, saying I am giving too much or too little fluid to the patient. I once took care of a septic patient and gave them absolutely no fluid, and they survived. So much for the so-called “evidence”. There is no amount of evidence that can replace intuition and sound clinical acumen. As many of you likely can affirm, a true clinician can almost feel the right thing to do. A challenge to this as the basis of medicine is akin to advocating a change from the “art of medicine” to the “science of medicine”. Blasphemy!

I am sure each of you have experienced some form of this assault. In fact, the medical literature today is full of direct attacks on eminence (1-3). The threat is becoming more acute by the day, as even the lowliest trainee has access to the entire world’s archive of medical literature in their pocket. To survive, we must arm ourselves and fight back. We must have at the ready an armamentarium of weapons and tools to stem the tide, and turn back the latter-day Visigoths who fling their regression analyses, critical appraisal tools, and “levels of evidence” at our battlements. What follows is an attempt to codify some of those tools, and help all of our eminent practitioners to soldier on in the fight.

1. “Harrumph and eye roll”. When confronted with what seems like sound evidence that counters the way you have treated something for many years, simply roll your eyes in a dramatic way, make a “harrumph”-ing sound quite loudly, and say something like “Well, balanced salt solutions may make physiologic sense, but normal saline has worked for me for many years.” The italics imply rhetorically stressing the avenue of attack chosen by the challenger, and throwing it back at them in a mocking, or sarcastic way, and then reminding them of how much more experience you have than they do. While seemingly basic and perhaps puerile, it is astounding how effective this technique can be. But the “harrumph” you throw in must be emphatic, and said with conviction. This technique rests entirely on how invested in it you can be.
2. “My specific patient is different”. These evidence cultists always want to assume that their numbers and ratios always apply to everyone. It is relatively simple to find some minor clinical difference between the particular patient under discussion and the participants in whatever trial your foe is citing. For example, when challenged on your management of a ventilated patient, you can say, “Well, in that trial, they didn’t specifically analyze the subgroup of patients with influenza and CHF, did they?” or “the secretions of influenza in a patient with CHF are clearly unique”. Defenses like this usually put them on their heels, as they will either have to go back to the trial itself to check, or admit that they are not quite sure.
3. “In my experience…” No matter how much evidence is presented, it is always possible to unearth the musty contents of your own shadowy past. Ill-defined and utterly unverifiable, your “experiences” with individual patients, if described colorfully and in detail, can easily counter dry references to impersonal literature reports. It can also refute arguments of physiology. If you have seen something before, your eye-witness account is much more reliable than some “deep understanding of physiologic principles”.
4. Question the quality of the training of the evidence-hound. No matter what they say or how many “facts” they can cite, one can almost always cast aspersions on their training in some way. “When I was at Harvard...” is a near-perfect oratory introduction to asserting your proper place.
5. Point out some minute problem in the design of the study being quoted. Although somewhat unsavory, as it may require stooping to the tactics employed by our attackers, it is always possible to take issue with some aspect of any given study. “I can’t believe they used a Kolmogorov–Smirnov test, when they clearly should have used Pitman’s permutation test. The results of this study are suspect to say the least.” This should require quite a bit of investigation by the whelp, by which time you should be safely ensconced in the doctor’s lounge.
6. Cite a report that supports your viewpoint. Again somewhat unsavory, but even when someone states that 3 randomized control trials (RCTs) have shown that a certain treatment is “clearly” superior to how you have been doing things, you can almost always cite a trial that does support you (“while it is interesting that those investigations show that digitalis is not effective in heart failure in general, Jones et al. showed that it reduced readmission rates in the Congo when given to patients with CHF due to parasitic disease...”). Always remember to end the discussion with “so clearly the jury is still out on this subject.”
7. Lean heavily on the axiom that “lack of evidence of efficacy is not evidence of lack of efficacy”. This is very powerful and can be carried quite far. No matter how many trials show that a treatment doesn’t work, this single sentence irrefutably ends discussion in most cases.
8. Utilize physiologic smoke screens. Delve deeply into your medical school texts, and have at the ready in depth discussions of biochemical and physiologic pathways. Learn to describe how they interact in such detail that no one can really follow what you are getting at, but throw in enough polysyllabic words and pathway intermediates and you are untouchable, no matter how much evidence is tossed around. In today’s world, most trainees’ education in biochemistry, physiology, and anatomy has been short-shrifted to a stunning degree by the addition of silly classes on biostatistics, ethics, diversity, professionalism, and other such drivel, so you can be generally assured they will have no comeback for this defense.
9. “Cookbook medicine”. Throw out derogatory terms such as “cookbook medicine” and wax nostalgic for the times when doctors truly “thought” about their patients and cared about them. This is particularly effective when you can question the humanity of your foe, asserting that “statistics and numbers can never substitute for the human being in the bed in front of you. You would do well to remember that.” Followed up with a moving patient story where your attention to detail and the history of that individual patient made all the difference, and where your diagnosis and treatment plan flew in the face of the naysayers, and you are safe.
10. Parachutes. Go nuclear, and question evidence itself. This is obviously high-risk, but can be very effective. Building on the excellent article utilizing the example of the parachute as a preventative treatment for high-altitude falls that has never been verified in a RCT (despite the fact that there are case reports of parachute-less high-altitude falls resulting in subject survival) (4), make the point that medicine is more than evidence. Rub their nose in the fact that true doctors can see the value in treatments that are of “obvious” value, even without evidence.
11. Question the work ethic or integrity of the evidence bearer. No matter what they say, find some fault with their daily routine, or pre-rounding attention to detail, or accuracy of information they provided about the patient. Proceed to vociferously point out their deficiencies, making sure that everyone in ear shot is aware of what is happening, and intimate that anything they say is suspect.
12. Trump them. If all else fails, utilize the debate technique made so famous by the current president. Previously known as “vehemence-based medicine” (5), simply raising the volume of your opinion and employing an attitude that your opponent is a complete and utter moron will shut down any opposition. With this technique, if employed correctly, any amount of logic or number of facts will wilt in the glare of your intensity and scorn.
13. Eloquence and elegance based argumentation. Much to the chagrin of the attackers, it is still well-accepted that “brilliant oratory,…a year round suntan, [and/or] a silk suit” (5) can overwhelm the senses of most of the sandal-wearing hippies who worship at the altar of evidence. Keep your style impressive and tighten your bowties!

Be strong, my brothers and sisters! While some furtive attempts have been made to fight back and harness the power of our eminence (6), we are clearly in danger. In the face of this growing threat, our ability to wield our eminence may falter. We hope that the techniques described herein will serve you well in our struggle. Let not these heathens question our place or sacred way of life. Stand tall, and continue to be the face of “EBM”.

References

1. Bhandari M, Zlowodzki M, Cole PA. From eminence-based practice to evidence-based practice: a paradigm shift. Minn Med. 2004 Apr;87(4):51-4. [PubMed]
2. Kros JM. Grading of gliomas: the road from eminence to evidence. J Neuropathol Exp Neurol. 2011 Feb;70(2):101-9. [CrossRef] [PubMed]
3. Pincus T, Tugwell P. Shouldn't standard rheumatology clinical care be evidence-based rather than eminence-based, eloquence-based, or elegance-based? J Rheumatol. 2007 Jan;34(1):1-4. [PubMed]
4. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ. 2003 Dec 20;327(7429):1459-61. [CrossRef] [PubMed]
5. Isaacs D, Fitzgerald D. Seven alternatives to evidence based medicine. BMJ. 1999 Dec 18-25;319(7225):1618. [CrossRef] [PubMed]
6. Hay MC, Weisner TS, Subramanian S, Duan N, Niedzinski EJ, Kravitz RL.Harnessing experience: exploring the gap between evidence-based medicine and clinical practice. J Eval Clin Pract. 2008 Oct;14(5):707-13. [CrossRef] [PubMed]

Cite as: Willis BC. In defense of eminence-based medicine. Southwest J Pulm Crit Care. 2017;14(2):69-72. doi: https://doi.org/10.13175/swjpcc019-17 PDF 

Qualitygate: The Quality Movement's First Scandal

Charles R. Denham is probably not a name familiar to most of our readers. Denham's name popped into the news when the Justice Department alleged that CareFusion, then a division of Cardinal Healthcare, paid Denham $11.6 million to influence the Safe Practices Committee at the National Quality Forum (NQF).

Dr. Charles R. Denham

Even though Denham may not be well known, readers might recognize the names of some of the organizations and individuals with whom Denham worked (2,3). Besides the NQF, these include the Institute of Medicine, Leapfrog Group, Centers for Disease Control and Prevention, Clinton Global Health Initiative, Discovery Channel, General Electric, Cleveland Clinic, Vanderbilt University Medical Center, Catholic Healthcare Partners, and Seton Medical Center. Prominent individuals associated with Denham include actor Dennis Quaid (whose newborn twins were nearly killed by a medication mistake) and Capt. Chesley "Sully" Sullenberger, famous for safely landing a crippled jetliner in the Hudson River. Lesser known, but prominent in the patient safety movement, are Dr. Kenneth Kizer (former Under Secretary for Health in the U.S. Department of Veterans Affairs and founding president and former CEO of the NQF) and Dr. Donald Berwick (founder and former President of the Institute of Healthcare Improvement and former Administrator of the Centers for Medicare and Medicaid Services).

Denham is a member of the President's Circle of the National Academies of Science of the Institute of Medicine, the National Academy of Sciences and the National Academy of Engineering. He has been a Senior Fellow in the Advanced Leadership Initiative at Harvard University and instructor at the Harvard School of Public Health. He teaches leadership and innovation on the faculty of Harvard Medical School and was an adjunct Professor at the Mayo Clinic College of Medicine. He played a leadership role in the development of a computerized prescriber order entry (CPOE) simulator that measures performance improvement of hospital medication management systems, driving patient safety through healthcare information technologies. He founded CareMoms, CareKids, and CareUniversity, which are programs that are focused on helping families survive healthcare harm and waste. He was until very recently the editor of the Journal of Patient Safety (4).

Many groups have benefitted by recommending best practices, but an endorsement by the NQF can mean riches for companies and individuals (4). Created in 1999 at the behest of a Presidential commission, the Washington, D.C.-based nonprofit takes private donations and collects fees from members, including consumer groups, health plans and medical providers. Five years ago, Health and Human Services hired the NQF to endorse measures to show whether health care spending is achieving value for patients and taxpayers. The contract has since grown substantially and by 2012 made up nearly three-fourths of the organization’s $26 million in revenue. The NQF’s standards are widely adopted. The report produced by the committee Denham co-chaired included recommendations for best practices in 34 areas of care.

The quality movement is distancing itself from Denham and denying any knowledge of Denham's conflicts of interest or alleged kickbacks (5). However, there were multiple clues. Although Denham was trained as a radiation oncologist, he was not a practicing physician (6). Known as an entrepreneur, Denham had formed and folded numerous for-profit and non-profit companies. Those listed by the Texas Secretary of State’s office include the Texas Institute of Medical Technology; Health Care Concepts; TD Enterprises Management; Spectrum Holdings International (also known as Austin Liberty, Inc.); Tetelestai, Inc. (Greek for “It is finished,” a New Testament reference); Aircare International, Inc. (Denham at one time worked in the aviation industry); CRD Health Ventures, Inc.; and Assisted Better Living Everywhere, Inc. Denham and his family live in a palatial waterfront home in Laguna Beach, California, whose value Zillow estimates at $10.5 million (6). The speaker’s bureau lists Denham’s minimum fee for U.S. engagements as an average of $50,000 to $75,000, far in excess of usual physician speaking fees (6). Denham even boasted his own webpage on Wikipedia and had a contract with Celebrity Talent International (2,4). Although Denham's biography in Wikipedia claims over 100 scientific publications a quick check of PubMed reveals only 25 with nearly all published in the last 5 years in the Journal of Patient Safety where Denham was editor.

In his article in Forbes, Michael Millenson quotes an accomplished patient safety advocate who left her first meeting with Denham convinced she had met with one of the most brilliant individuals of her life (4). Those who know Denham suspect that he would agree (6). The tendency of very smart and successful individuals to boss others is well known because in their own minds they are smarter and better, even when the evidence says otherwise. Some can even blur the boundaries between what they have done, what they are doing and what they hope to do-convincing themselves that it is in the patients' best interests. Like Watergate did to the Nixon White House, Denham has tainted many in the quality movement. Hence the title of this editorial-"Qualitygate". A lot of money is involved in patient safety and there are undoubtedly some willing to sacrifice principles for personal gain. This will probably not be the last scandal in the quality movement. As we have noted previously, there are probably too many guidelines based on expert opinion and some are wrong (7). Physicians need to exercise their own best judgment in deciding which guidelines need to be implemented.

Richard A. Robbins, MD*

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Department of Justice Office of Public Affairs. CareFusion to pay the government $40.1 million to resolve allegations that include more than $11 million in kickbacks to one doctor". Available at: http://www.justice.gov/opa/pr/2014/January/14-civ-021.html (accessed 2/21/14).
2. Wikipedia. Charles Denham. Available at: http://en.wikipedia.org/wiki/Charles_Denham (accessed 2/21/14). 
3. Newswise. Dr. Charles Denham named editor of Journal of Patient Safety. Available at: http://www.newswise.com/articles/dr-charles-denham-named-editor-of-journal-of-patient-safety (accessed 2/21/14).
4. Allen M. Hidden financial ties rattle top health quality group. Propublica. Available at: http://www.propublica.org/article/hidden-financial-ties-rattle-top-health-quality-group (accessed 2/21/14).
5. Carlson J. Groups cut ties to Denham. Modern Healthcare. Available at: http://www.modernhealthcare.com/article/20140201/MAGAZINE/302019962 (accessed 2/21/14). 
6. Millenson M. The money, the MD and a $12 million patient safety scandal. Forbes. Available at: http://www.forbes.com/sites/michaelmillenson/2014/02/14/the-money-the-md-and-a-12-million-patient-safety-scandal/ (accessed 2/21/14).
7. Robbins RA. What's wrong with expert opinion? Southwest J Pulm Crit Care. 2014;8(1):71-3. [CrossRef]

*The views expressed are those of the author and do not necessarily represent the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. Qualitygate: the quality movement's first scandal. Southwest J Pulm Crit Care. 2014;8(2):132-4. doi: http://dx.doi.org/10.13175/swjpcc022-14 PDF

Why Start A New Pulmonary/Critical Care Journal?

Reference as: Robbins RA. Why start a new pulmonary/critical care journal? Southwest J Pulm Crit Care 2010:1:1-2. (Click here for PDF Version)

With apologies to Paul McCartney, “You'd think that people would have had enough of [pulmonary and critical care journals]. But I look around me and I see it isn't so” (1). With the inception of the Southwest Journal of Pulmonary and Critical Care (SWJPCC) we have several goals, not adequately filled by the present pulmonary and critical care publications.

First, the primary goal of the SWJPCC is pulmonary and critical care medicine fellow education. The American College of Graduate Medical Education has placed increasing requirements for clinical education in post-graduate medical education while simultaneously increasing the requirements for scholarly activity for fellows and faculty, yet restricting fellow work hours (2). It seems that these conflicting goals are unrealistic, unless clinical scholarly activity can be incorporated into a training program. In starting the SWJPCC, we hope to fulfill the scholarly needs of both fellows and faculty while emphasizing clinical medicine through the publication of such time honored activities as case presentations and reviews of the literature.

Second, peer-reviewed journals send articles out for review. While we will do the same, we have certain expectations of our reviewers. Unfortunately, reviewers are not always carefully chosen.  Sometimes inexperienced reviewers, feeling the need to establish themselves, indulge their own sense of self-importance by becoming “nagging nabobs of negativism” (3) demanding the answer to “the ultimate question of life, the universe and everything” (4) before a manuscript will see the light of publication. While emphasizing the highest medical journal standards, we realize that fellow and faculty time is limited and we hope to be reasonable regarding expectations of our authors.

Third, there has been a trend in some journals towards publishing articles emphasizing the “short-comings” of physicians while emphasizing the virtues of identifying these “faults”. For example, the New England Journal of Medicine published an article from a health regulatory organization (the Joint Commission), touting improved healthcare through administration of the pneumococcal vaccine to adults (5). This article implied that physicians who did not provide this vaccination to their adult patients were delinquent, and the Joint Commission’s efforts “corrected” this deficiency. However, previous publications have shown that pneumococcal vaccination in older adults results in a slight increase in the risk for hospitalization, but does not decrease mortality nor the risk for pneumonia (6), findings largely confirmed by a recent meta-analysis (7). Publication of articles substituting politics or opinions (especially when they are self-serving) for evidence-based care is not part of the mission of the SWJPCC.

Last, the SWPCC aspires to be a resource for practicing physician education, emphasizing case presentations, clinical articles, review articles, imaging, and journal clubs. We hope this journal will be useful for busy clinicians, assisting them in better serving the needs of their patients while also providing insight regarding practice matters of interest to the pulmonary and critical care medicine community.

With that, we begin.

Richard A. Robbins, M.D. on behalf of the Editors

References

1. McCartney, Paul. “Silly Love Songs”. Wings at the Speed of Sound. Palorphone/EMI, 1976.
2. http://www.acgme.org/acWebsite/nav/Pages/navPDcoord.asp
3. Agnew, Spiro. San Diego, CA. 1970.
4. Adams, Douglas. Life, the Universe and Everything. ISBN 0-330-26738-8.
5. Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. hospitals--the Hospital Quality Alliance program. N Engl J Med. 2005;353:265-74.
6. Jackson LA, Neuzil KM, Yu O, Benson P, Barlow WE, Adams AL, Hanson CA, Mahoney LD, Shay DK, Thompson WW; Vaccine Safety Datalink. Effectiveness of pneumococcal polysaccharide vaccine in older adults. N Engl J Med. 2003;348:1747-55.
7. Huss A, Scott P, Stuck AE, Trotter C, Egger M. Efficacy of pneumococcal vaccination in adults: a meta-analysis. CMAJ. 2009;180:48-58.