This document discusses evidence-based improvisation in medicine. It begins by defining evidence-based medicine as the conscientious use of current best evidence in patient care decisions. Improvisation is defined as spontaneous creation without preparation that involves constant adjustment. The relationship between science, practice, formal and informal knowledge is explored. Evidence-based medicine involves clinical expertise, best research evidence, and shared decision-making. When evidence is limited, improvisation based on expertise is needed to tailor care to each unique patient. Overcoming obstacles like bias and focusing on the patient-clinician relationship are keys to effective improvisation.

1. Evidence-Based Improvisation
John D. Wynn, MD, DFAPA
Medical Director for PsychoOncology & Supportive Care Services
Swedish Cancer Institute
Clinical Professor of Psychiatry & Behavioral Sciences
University of Washington School of Medicine

2. Thoughts for today
 What is evidence-based medicine?
 What is improvisation?
 What is the relationship between
 Science and Practice
 Formal and Informal knowledge
 Knowing what to do and figuring out what to do

3. Evidence-Based Medicine
Care
Communicatio
n
Clinical
Expertise

4. Martin

5. Martin
 42yo architect
 Happily married, two small children
 Creative, productive, exuberant, cosmopolitan
 Seizure at work
 Evaluation: glioblastoma
 Prognosis: poor
 Treatment: bone marrow transplant, chemotherapy, g-knife
 Presentation:
 6 years later
 Active, energetic, searching for meaning
 persistent suicidal ideation

6. Evidence Based Medicine
 “Conscientious, explicit, and
judicious use of current best evidence
in making decisions about the care of
individual patients.”
Sackett DL et al:Evidence based medicine: what it is and what it isn’t.
BMJ 1996;312:71
doi:http://dx.doi.org/10.1136/bmj.312.7023.71

7. Improvisation
improvise |ˈimprəˌvīz|
verb
• to create and perform (music, drama, or verse) spontaneously
or without preparation.
• produce or make (something) from whatever is available.
• from Latin improvisus ‘unforeseen,’ ‘unprovided for’
Oxford English Dictionary

8. “It is the most normal thing in the
world to improvise.”
We improvise every time we say a sentence —in fact we are
improvising all the time, creating all the time.
Stephen Nachmanovitch
Quoted by Channing Gray, "Improvising on the violin: Stephen Nachmanovitch fills his
concerts with musical insights," Providence Sunday Journal, 27 May 1990

9. Stephen Nachmanovitch
 “Improvisation means presence: it doesn’t mean acting
wild or crazy or doing random things…it’s intensely and
immensely structured; it’s presence and responsiveness
to what’s there.”
 “Doing, doing doing, testing, testing, testing, seeing how
things work out, correcting yourself, changing as you go
along…’til you get something you like.
 “And that happens microsecond by microsecond…you’re
always a little off course, always correcting, and that’s
improvisation in daily life.”

10. Evidence Based Medicine
Key Components:
1. Clinician expertise
2. Best available systematic research
3. Shared decision making
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS
Evidence based medicine: what it is and what it isn’t.
BMJ 1996;312:71
dx.doi.org/10.1136/bmj.312.7023.71

11. Are you an expert?

12. Clinician expertise
 “The proficiency and judgment that individual
clinicians acquire through clinical experience and
practice.”
 Reflected in more…
 effective and efficient diagnosis
 thoughtful identification and compassionate
use of each patient’s predicaments, rights, and
preferences
Sackett DL et al:Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71
dx.doi.org/10.1136/bmj.312.7023.71

13. Levels of Evidence
Ia - Meta-analysis of Randomized Controlled Trials
Ib - Randomized Controlled Trial
IIa - Well designed (but not randomized) controlled trial
IIb - Well designed experimental trial
III - Case, correlation, and comparative studies.
IV - Evidence from a panel of experts

14. Evidence Based Medicine:
Expertise + Evidence
 Without current best evidence,
 Practice risks becoming rapidly out of date
 Patients will suffer
 Without clinical expertise,
 Practice may be tyrannized by evidence
 Even excellent external evidence may be inapplicable or
inappropriately applied
 Guidelines must be integrated with expertise
 to match patient's clinical state, predicament, preferences
 to decide whether they should be applied.

15. Expertise + Evidence + Improvisation
Science is not enough
It’s what you do with the science

16. Shared Decision Making
 “Probably the most difficult and poorly mapped step – yet it
receives the least attention.”
 Essential component of EBM
 Eliciting the patient’s preferences
 Understanding the patient’s values
 Informed consent
 Natural history, treatment options, benefits & harms
 Depends on quality of the evidence
 Requires clear communication
Hoffman TC et al:The connection between EBM and shared decision making.
JAMA 312(13)1295-6, 2014

17. Martin
 Treatment
 Psychotherapy
 Labeling and substituting
 Search for meaning
 Mortality and loss
 Behavioral activation
 Pharmacology
 Citalopram
 Escitalopram
 Venlafaxine
 Sertraline
 Response: no better

18. Now what?

19. Limitations of the Evidence Base
 Problems don’t fit established category
 Problems occupy overlapping categories.
 Established treatments don’t work.
 Complications arise despite effective treatment.
 Evidence Misapplied
 The evidence is irrelevant or misinterpreted
 The diagnosis is wrong

20. Pharmacology
 Check relationship: belief, expectations, adherence
 Rx rationale
 Time course, side effects, interactions
 When, how, if taking as prescribed
 Review what you’re already doing, then…
 Treatment refractory guidelines?
 Combination therapies: little supporting data
 Beg, borrow, steal
 psychiatry, neurology, general medicine, surgery…

21. Psychotherapy
 Check relationship: belief, expectations, adherence
 Engagement
 Hope
 Creative process?
 Review what you’re already doing, then…
1) Try a more orthodox approach
Do what you’re already doing, more diligently
2) Try an alternative orthodox approach.
3) Try a more heterodox (“eclectic”) approach.

22. EBI?
 All of medical practice is improvisational
 Every patient unique
 Clinical expertise essential
 “Current best evidence” may not provide…
 Any guidance at all
 General, but no specific intervention
 The best approach to a particular patient
 So: improvisation based in evidence?

23. What do we do when…
You have an unusual situation for
which there is no reliable evidence?

24. Martin

25. Next steps?
 Check the relationship
 Communication
 Rx rationale
 Adherence
 Review what you’re already doing
 Back to the evidence…

26. What do we know?
︎✓ Glioblastoma surgery, chemotherapy
✓ Seizures
︎✓ Depression
︎✓ Symptom management
✓ Fatigue, anorexia, insomnia
✓ Dysphoric cognition
✓ Suicidality
? This patient

27. “There is currently no high-quality evidence
as to whether pharmacological treatments for
depression in patients with primary brain
tumors are effective, or harmful.”
Rooney A, Grant R. Pharmacological treatment of depression in patients with a
primary brain tumor. Cochrane Database of Systematic Reviews 2013, Issue 5.
Art. No.: CD006932. DOI: 10.1002/14651858.CD006932.pub3.

28. When do we improvise?
 Encounter
 Engagement
 Examination
 Assessment
 Treatment Planning
 Treatment

29. Expertise + Evidence
+ Improvisation
It’s the relationship…

30. Samuel
micro-moments

31. He tries, you try, he tries…
 Entry
 Begin
 Respond
 Affirmation
 Reply
 Next question…

32. What structures our improvisation?
 Expertise
 What to look at and look for
 What kinds of hypotheses are required
 Self-awareness: our skill and preferences
 Mindfulness?
 Perception
 Reaction
 Distinguishing expert knowledge from intuition
 Formally acquired vs. subconsciously adopted
 Data-driven vs. fruits of experience

33. Experience yields paradox
 Expertise:
 Strongly-held beliefs
 Humility
 Deeper knowledge:
 Caution
 Willingness to experiment, to risk

34. General in the unique,
unique in the general
 Every person
 is unique
 demonstrates idiosyncratic patterns of feeling,
thinking, and behavior
 Medical care requires
 putting people in categories (diagnostic classification)
 close attention to what is typical
 common and predictable
 In every unique patient

35. Theme and Variation
 Everyone has a theme
 Appears almost immediately
 Restated over and over
 Once you find it, you can join in…
 We engage in response, but also in anticipation
 Expectations set up our perception
 It takes focus to see what is unexpected
 We – all of us – are ourselves over and over

36. Meeting the Patient’s
Improvisation
 Every clinician/patient encounter a duet
 Biases and skill will determine how you…
 …seek out and identify the theme
 …anticipate and respond to restatements of the theme
 …help the patient identify productive and
unproductive patterns
 Thinking
 Feeling
 Behavior

37. What gets in the way?

38. Clinician obstacles to effective care
 Ignorance and Habit
 Time pressure
 Lack of preparation
 Judgment errors
 Lack of humility; shame
 Counter-transference

39. Overcoming Obstacles
 Ignorance, habit
 Time pressure
 Lack of preparation
 Judgment errors
 Lack of humility
 Counter-transference
 Patient-based learning
 Spreading out the work
 Patient-based learning
 Practice, follow-up, peer review
 Practice,
follow-up,
coaching,
psychotherapy…

40. There is nothing that deceives us more
easily than our confidence in our
judgment, divorced from reasoning.
Leonardo da Vinci (1452-1519)

41. Martin
Is he depressed?

42. Evidence-Based
Improvisation
Physiolog History Patholog

43. Evidence-Based
Improvisation
Listening Organizin
g
Query
Physiolog History Patholog

44. Evidence-Based
Improvisation
Patience Empathy Compassio
n
Listening Organizin
g
Query

45. Evidence-Based
Improvisation
Communication
Patience Empathy Compassio
n
Listening Organizin
g
Query

46. Expert Improvisation
Communication
Listening Organizin
g
Query
Physiolog
y
History
Pathology

47. Improv, anyone?
 Perplexing behavior
 Chronological
disorganization
 Dissociation
 Incongruous body
language
 Upsetting behavior
 Anger - episodic, persistent
 Argumentativeness
 Physical threats
 Couples
 Hateful patient
 Boundary issues
 Tardiness
 Absenteeism
 Failure to engage despite
overt intent to continue
 Web searches…
 Sexual overtures…

48. Questions?
John D. Wynn, MD
206-624-0296
john.wynn@swedish.org

49. Improvisation
Innovation
Integrity
Insight

50. Without evidence,
what have you got?

51. Ars longa, vita brevis
The work is long,
but life is short;
the crisis fleeting;
experience misleading;
and judgment difficult.
— Hippocrates
460–370 BCE

52. David Sackett, MD
“Half of what you'll learn in medical
school
will be…either dead wrong or out of date
within five years of your graduation;
the trouble is…
nobody can tell you which half,
so the most important thing to learn
is how to learn on your own.”

53. “It ain’t what you don’t know
that gets you into trouble.
It’s what you know for sure
that just ain’t so”

54. I
n
n
o
v
a
t
i
o
n
&
r
i
s
k

55. We are here not to offer an alternative to EBM, but rather to
explore the clinician’s daily struggle with meager, or non-
specific evidence, and to provide excellent care in its absence.
This is not a reaction against "cookbook medicine", or other
charges against EBM. We are embracing the struggle of day-
to-day medical practice that inspired EBM in the first place