If you have ever been confronted by an Evidence-Based Medicine (EBM) “zealot,” you know that we can be quite persistent.
We EBM zealots (like our religious counterparts) have become accustomed to the knee-jerk resistance, and so we are prepared for a potentially long conversation – even multiple conversations. When my newest “target” begins to show the telltale signs of resistance, I take a deep breath because I’m in it for the long haul. Recently, while having a conversation about the lack of evidence to support the use of epinephrine in Advanced Cardiac Life Support, I noticed my “target” colleague was conspicuously exhibiting the Kübler-Ross model for the Five Stages of Grief.
As he attempted to defend the tradition of using epinephrine, I watched him come to terms with the implications of acknowledging the importance of assimilating high standard, rigorous EBM into his clinical approach. This could literally change most of what we do as physicians. I was struck by how similar it was to observing a mourner.
Stage 1: Denial
“This can’t be true,” and “I was taught that it works!”
At first, it seems impossible that American Heart Association Guidelines have been repeatedly shown to have no efficacy other than to lengthen ICU stays before death or lead to higher numbers of discharged patients with poor neurological outcomes. However, if we acknowledge this – if we swallow that bitter pill – we may be consigning ourselves to confronting almost every facet of what our mentors taught us. This is unpleasant, cognitively scary, and even painful. The reflex is to kick back and defend unproven but dogmatic practices. “It makes sense theoretically,” or “it should work” are typical replies.
“Very smart people – people smarter than you – believe in this” and “I’ve seen it work myself” are two more expected responses, both problematic. The former replaces critical thinking with fealty and blind faith; fine for a beginning student but not for an advanced student or practicing doctor. The latter relies on anecdote, which, as has been noted by others, is not data (even in plural, unless it is somehow quantified and measured). We go into Denial because it is painful to accept that we may have had excessive trust in authority of our admired teachers and feared exams.
Stage 2: Anger
Anger in confronting EBM zealots comes in two forms: First, “Why did I waste all this time learning false things?” is a very understandable and appropriate emotion. Second, “targets” sometimes attack the messenger, not the message. One typical response ascribes arrogance to the EBM zealot. “How can you have the audacity to say that the AHA is stupid?”