Evidence-based medicine must link with personal judgment

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Rita Charon, MD, PhD. Source: Columbia University  

A group of clinicians and scholars at Columbia University has undertaken a program that attempts to integrate narrative-based medicine and evidence-based medicine, while trying to illuminate their fundamental unities, according to an article in the Jan. 26 issue of the Lancet.

Evidence-based medicine (EBM) offers hope that good data can point to good actions and proposes that clinical decisions be made on the basis of trustworthy evidence, deployed by clinicians who use their clinical judgment and take into account the patient's values and circumstances, co-authors Rita Charon, MD, PhD, and Peter Wyer, MD, wrote.

In response to this clinical “authoritarian” EBM push, narrative based medicine (NBM), “reminds doctors that illness unfolds in stories, that clinical practice transpires in the intimacy between teller and listener, and that physicians are as much witnesses to patients' suffering as they are fixers of their broken parts.”

A final unifying step—called narrative evidence based medicine (NEBM)—may be found in a combination of the two methods, according to the article.

“NEBM is medicine practiced with full access to the many forms of evidence required for effective practice: credible clinical research findings; singular disclosures from the patient about his or her circumstances, values and preferences; and interior heeding to personal diagnostic and management judgment,” Charon, a general internist at Columbia Presbyterian Hospital in New York City, told CVB News.

In the article, the NEBM Working group at Columbia said that their project recognizes the narrative features of all data and the evidentiary status of all clinical text.

“The skilled clinician does not first collect and deploy evidence and then soften it up with narrative; rather he or she is always already embarked on grounded, rigorous, personal, particular, and perilous interpretations that, like any hypotheses, can be tested for trustworthiness and utility,” the authors wrote.

Charon clarified how this new methodology separates itself from the gold-standard approach.

“NEBM is similar to EMB in its insistence on basing practice on credible evidence. NEMB differs from EMB in not restricting salient evidence to the epidemiological or research evidence,” Charon said.

The working group wrote that it hopes their study will lead “clinicians to search out training to develop not only their knowledge of dutiful use of clinical research findings but also training to capture the singular evidence emitting from patients and, from within, from the clinician himself or herself. This will require training in reflective practice and attentive and attuned contact with patients.”

Charon said that if NEBM is effectively utilized, the “care will be fitting, the decisions mutually reached, the process of care mutually nourishing, and the recognition achieved will not be at the cost of scientific accuracy.”

She added, “Cardiologists would learn to take personal aspects of the patient and of the clinician into consideration when reaching decisions with or even for patients. They would proceed in their practices with the awareness that the relation between doctor and patient is the fundamental aspect—and engine—of care.”

Narrative-evidence based care probably takes more time, Charon said, but in the long term it can be cost-effective. It can limit unnecessary tests, those done only because participants don't trust one another, and it reduces error because the patient becomes more transparent to the doctor, especially over the long haul.