“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.
Objectives
• Perceived conflicts between EBM and
clinical experience
• Problems associated with relying solely on
clinical experience- self/experts
• Restructuring into harmony- “clinical jazz”
Clinical Experience
• The fertile ground from which ideas and
hypotheses grow
• Major conflict: Experience doesn’t jibe
with research-based evidence
Clinical Experience
• Not a source of valid POEMs
• Multiple validity problems
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
Clinical Experience - Validity
• Small sample size
• “Stacking the deck”: Biased allocation to
treatment groups
• “Rose-colored glasses”: Biased
assessment of outcomes
“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 for
PUD (Barry Marshall), home glucose monitors
Experience: A problem of perception
Do you see the Dalmatian
in the picture?
• 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
www.optillusions.com
4
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
They really are!
Clinical Experience
Not really in competition with EBM
Combining EBM and Experience:
“Clinical Jazz”
Structure
plus
Improvisation
Clinical Jazz
Improvisation without structure =
cacophony
Clinical Jazz
Structure without Improvisation=
tedium
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
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!
Clinical Improvisation - Opportunities
• Conditions with no valid POEMs
– e.g. Screening for prostate cancer
• Conditions with multiple valid POEMs
– e.g. Depression
Clinical Improvisation - Opportunities
• Patients whose characteristics differ from
those of patients included in research studies
• Implementation methods for valid POEMs
Clinical Improvisation - Potential
Sources of Inspiration
• Clinical Experience
• Colleagues’ Ideas
• Local Experts & Consultants
• “Standard of Care”
• DOEs
• Others
Clinical Improvisation
Not a Solo Activity
• Including the patient’s perspective
• Working with a clinical team
• Working with consultants
• Working with partners
“If you can’t listen,
you can’t play jazz”
Wynton Marsalis
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
Circle of Clinical Reasoning
Patient seen
in practice
Clinical
Judgment
Outcomes
Research
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 “KeflexReflex” (How low do you need to go?)
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
Flaws in the Circle of Reasoning
• Must consider overall effect on population
(disease-specific vs all-cause mortality)
– PSA: may decrease deaths from prostate CA
• Overall may harm more than help (quantity or quality of life)
– Colon/breast CA- Less CA deaths, more CV
deaths/year compared with control
• 2/10,000/year fewer CA deaths
• 2/10,000/year more CVD deaths
• Bill and Jane die sooner so Frank and Judy live longer
– Patient-specific vs population-based screening
• Need for personal decision analysis using utilities
• Wisdom vs knowledge vs information
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
“Mundus Vult Decipi”“The world wishes to be
deceived”
People would rather be
deceived than have the truth
create anxiety.
-Caleb Carr, “Killing Time”
“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
“America’s two greatest gifts to the world
are jazz and Medline.”
--Richard Smith, BMJ 2001
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
“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