Surviving Evidence-Based Quicksand

Illustration by Jennifer Bogartz

Writer and journalist E.B. White in his well known book on writing titled The Elements of Style had commented:

“Be obscure clearly. Muddiness is not merely a disturber of prose, it is also a destroyer of life, of hope: death on the highway caused by a badly worded road sign … think of the tragedies that are rooted in ambiguity, and be clear!”

As a family doctor with nearly forty years of clinical practice under my belt, I have found the same concept can and should be applied to the field of medicine. I work hard at clarifying the obscurity of the human condition in my job, relying on my patients to clearly provide the information I need to make a sound diagnosis and treatment recommendation.

Communication is hard work for many patients, especially when they are depressed and anxious on top of whatever they are experiencing physically. There is still too much unknown to fully understand the psychology, physiology and anatomy of humans. Then, throw in a disease process or two or three to complicate what appears to be “normal” and further consider the side effects and complications of various treatments. Evidence-based decision making isn’t perfectly equipped to produce the best and only solution to a problem.

Sometimes the solution to a patient’s symptom is very muddy and obscure, not at all pristine and clear. It is the physician’s job to try to bring everything into focus.

A physician’s clinical work is challenging on the best of days when everything goes well. We see things we’ve never seen before, expect the unexpected, learn skills we never thought we’d need to know, and attempt to make the better choice between competing treatment alternatives. Physicians constantly unlearn things we thought were gospel truth, but have just been disproven by the latest, double blind controlled study, which may soon be reversed by a newer study.

We find ourselves standing on evidence-based quicksand even though our patients trust that we are giving them rock-solid advice based on a foundation of truth learned over years of education and training. Add in medical decision-making that is driven by cultural, political, or financial outcomes, rather than what works best for the individual, and our clinical clarity becomes even more obscured.

Forty years of doctoring in the midst of the mystery of medicine means learning, unlearning, listening, discerning, explaining, guessing, hoping, and remaining very humble in the face of a disease process. What works well for one patient may not be appropriate for another despite what the best evidence says or what insurance companies and the government are willing to cover. Each individual we see deserves the clarity of a fresh look and perspective, instead of being treated by cook-book algorithm.

So be obscure clearly. A life may depend on it.

Dr. Emily Gibson is a family physician, farmer, poet, wife, mother and grandmother. She has worked in inner city primary care, community and rural health, detox and sexual assault centers, and as the medical director of a University Student Health Center for three decades. Both a photographer and writer, she shares daily about her life and work on her Barnstorming blog.

Dr. Gibson is a 2018–2019 Doximity Author.

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