Getting the evidence the challenge of medicine in tough global environment
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Getting the evidence the challenge of medicine in tough global environment
- 1. GETTING THE EVIDENCE The Challenge of Medicine in Tough Global Environments
- 2. NO CONFLICTS
- 3. “Evidence-Based Medicine is the Intersection of: • Medicine for which there are accepted data upon which to make recommendations • Medicine for which there are clinical experiences upon which to make recommendations • Medicine that will improve the situation in the eyes of the patient – the proof is in the eyes of the beholder
- 4. How is Medicine Practiced in a Tough Global Environment? • It’s the best that can be done, however that’s defined • It’s frequently constrained by limited resources • It’s often based more on practicality and compassion than on clinical decision rules • Traditional data collection may suffer and observations (not tests and facts) become more important, because improvisation is necessary
- 5. What’s a Really Difficult Environment? • Wilderness medicine – extreme and/or austere • Conflict and combat • Disaster
- 6. What’s a Really Difficult Environment? • Impoverished populace • Underserved patient population
- 7. What’s a Really Difficult Environment? • Developing or dysfunctional nation
- 8. What’s a Really Difficult Environment? • Not enough time to establish a caring relationship with patients and also keep up with the latest advances in medicine
- 21. Not yet! Stay tuned for: “In Reply to Evidence-Based Treatment of Jellyfish Stings in North America and Hawaii”
- 22. What’s a Really Difficult Environment? • Current regulatory - political - economic climate surrounding healthcare
- 23. U.S. Healthcare is Not in Need of Repair • We would be fine if there wasn’t a single advance in medicine. We should just stop smoking and begin to eat properly. • We live well, and we live long enough. • We should focus on bringing the rest of the world up to a decent medical standard, eliminating childhood diseases, ending war and poverty, and protecting the environment.
- 24. What Evidence Do We Really Need? • The effects of environmental change on human health
- 25. What Evidence Do We Really Need? • How to implement a compassionate and moral approach to death and dying while avoiding the ICU
- 26. What Evidence Do We Really Need? • That our leaders and legislators are counseled by people knowledgeable about healthcare and the doctor-provider relationship
- 27. What Evidence Do We Really Need? • Whether or not pharmaceutical company- sponsored research can or cannot be completed in an ethical, unbiased manner
- 28. Do you have to do the best than anybody can do? or Is it enough to do the best you can?
- 29. In my world, life can be random, and is certainly not controlled.
- 30. When the Power is Out, All You Have is What’s in Your Head
- 31. What Would Make the Situation Better?
- 33. Requests to the Evidence-Based Medicine Community • "The accurate recording of inaccurate data is not a useful pastime.“ (Eugene Stead) Speak openly about mistakes in EBM. • Tell stories and make them relevant to clinical practice; bring EBM to where the providers live. • Be uplifting about the future of medicine. • Allow EBM to maintain physicians as craftspersons, not assembly-line workers. • Take on tough global issues. Make social responsibility the heart and soul of medicine.
Editor's Notes
- Thanks for having me here. I’ve learned a tremendous amount from the experts who’ve addressed this audience. The need for evidence-based medicine is clear. But I think we need to consider the capabilities and needs of a generation of doctors who were educated in a different time or who practice in places where resources are scarce. I’ll preface my comments by saying that we all want to do the right thing. But that’s not always easy. I hope you find my comments thought provoking and not nihilistic.
- I have no conflicts to report other than the situations I find myself in from time to time, such as here in Haiti immediately after the 2010 earthquake.
- This is my understanding of evidence-based medicine. It’s clearly not just having the latest facts out of context for the situation of the practitioner and patient.
- I find myself in difficult environments more often these days. These can be on a mountainside or far out at sea practicing wilderness medicine, in a global humanitarian relief situation, or even in the midst of a disaster.
- These are all situations with which I’m familiar, and in which the practice of medicine can be much more critical than what we encounter on a routine basis in our protected environments. Most of us, even in emergency medicine, get handed out patients on a silver platter, before we irradiate them to the maximum extent possible.
- Reconstruction of the Hospitalito after the devastation of Hurricane Stan
- Nepal Ambulance Service
- So, what’s the value of experience? You know, the good old-fashioned kind, where the older you get, the wiser you’re supposed to become. To that, I’d also add intuition and common sense.
- Up in the mountains, we’d love to have evidence about the best ways to treat mountain sickness and other forms of high-altitude-related problems. But mountain medicine being what it is, there are a lot of opinions and not a whole lot of facts, because who’s willing to serve as the control?
- On a recent trip to Mt. Everest, we wound up running a helicopter shuttle service.
- My next adventure involved a fellow who kept me up three nights in a row because he was convinced that he had high altitude pulmonary edema. Notice the expression on the face of the fellow on the right side of the picture.
- My favorite wilderness activity is being underwater. I currently serve as the main consultant to the Divers Alert Network on the topic of how to diagnose and treat hazardous marine animal injuries.
- This is an example of the kind of stuff I get called for. Jellyfish stings can be really nasty, so…
- Working in this field has provided me my first opportunity to become involved as an author on evidence-based medicine, unfortunately to criticize what I think is an abuse of the concept. It also raises the question, “Is experience evidence?”
- In my forthcoming letter to the Editor, I point out that I’ve personally observed and treated more than 100 moderate to severe jellyfish stings around the globe with vinegar…
- Here’s perhaps the most difficult environment of all – the seemingly endless debate about what constitutes quality in healthcare. Evidence-based medicine has the opportunity to be a moralizer, but applied in a punitive fashion, could perhaps become a demoralizer. More about that a bit later.
- Consider for a moment that perhaps healthcare in the U.S. is not in need of repair. Then what would we focus on? Here are my thoughts.
- I’d like to see the evidence-based community consider bigger issues than how soon after the diagnosis of pneumonia is contemplated antibiotics should be started. Doctors are the most respected profession in the world and need to help the world cut through the political and corporate malfeasance that prevents us from getting to the important truths.
- Why do we need to know this? Because we need money to do research, and if government funding is diminishing, something needs to fill the gap.
- Finally, let’s never lose sight of providers, even us old old guys. At my institution we spend a lot of time celebrating the prize winners. We need to spend more time honoring the folks in the trenches.
- So, as you guide medicine into the inevitable future of evidence-based medicine, please recall that for many of us, there are situations that are beyond our control.
- In the absence of computers, PDAs, and telemedicine capabilities, when the power is out, all you have is what’s in your head.
- In that situation, the only thing that can improve the situation is communication.
- So,in a tough environment, when the evidence is available, we need to bring it. I mean, like in sports, we need to really BRING it.
- I’d like to conclude by making a few requests of the evidence-based medical community.