Evidence-based medicine, then and now


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Twenty years ago we practiced medicine very differently from today. Then, the physician was the center of care, not the patient. We relied on a paper chart…and could only hope that someone saw the one line about the patient that was really important, because if it was missed it might change the decisions that we made.

Medical research involved going to a library, which today seems very antiquated. But back then, that's how I researched cases. I went to our library, spent some time, and hopefully found myself on the path toward finding the right information. Sometimes it took days to come up with a specific plan for my patients.

Back then, I could never have envisioned where we’d be today. I believe several things have brought us to this point:

  • Patients have become closer to the center of their own care and are helping to direct what they want done.
  • Technology has evolved.

Think about the Internet and what it has done for availability of information. Or the fact that we have all moved down the path of electronic health records and have digitized almost everything we know about our patients.

There also is the whole concept of mobility. It was not that long ago that people thought of smartphones as appropriate for only a handful of mostly tech professionals. But now, 90 percent of physicians run around with one – and almost all of them have tablets of some kind as well.

This has all combined to make evidence-based medicine more sophisticated than ever before. Between the Internet and our mobile devices, we can ask very intelligent questions and receive very sophisticated answers…in our office, at the bedside and in the exam room.

This is a significant improvement. Studies show that two out of three clinical encounters generates a question. If all those questions were answered, it could change up to eight management decisions each day. Yet only 40 percent are answered. In my practice, we use online resources like UpToDate to get answers to our questions. It gives us information that is uniquely evidence-based, practical and sufficiently detailed for us to implement the recommendations with confidence.

Indeed, numerous studies have documented the impact of evidence-based clinical decision support systems on medical education and continual learning among students and clinicians who have already completed their training.

How does all this connect to patient care? I believe that it increases visibility. We know more about our patients. We know more about medicine. We have greater visibility into evolving medical evidence and best practices than ever before.

It is amazing that within seconds, we can come up with a very specific plan for managing a patient’s care – something that just a few short years ago took days.

At our own institution, we are seeing a lot of things change because of the use of technology. For example, we know that about a thousand times a day our physicians are logging into UpToDate, among other resources, and are asking better, more pointed questions. It is influencing their care decisions almost all the time, which is really fascinating.

I have seen the contrast now between physicians like myself who have been in practice for 20 years compared to the younger ones who are coming out of medical school today. We all believe the same thing. Part of our toolset -- our “doctor bag” if you will -- has to be the technology that we use. The rate of change in healthcare, the amount of information, the expectations that people have of our care, is changing so quickly that it requires the speed of technology to get us there.

Mrunal Shah, MD, ABFM, is a practicing physician, board-certified in primary care. He is also a System Vice President of Information Services and Faculty in Family Medicine in Columbus, Ohio.