Nancy Pelosi channeled the above phrase from an unknown source in the political sphere. But in the sphere of medicine, sometimes clinicians are confronted with the case that, in fact, no data exist and all that's left to help guide decisions are the plural of anecdote, whatever that may be called.
Here's a NEJM article in which pediatricians Stanford confront the problem. Of note, among the various fields in medicine, few are as poorly researched as pediatrics:
Without clear evidence to guide us and needing to make a decision swiftly, we turned to a new approach, using the data captured in our institution's electronic medical record (EMR) and an innovative research data warehouse.
They simply did a quick case-control study withing their own institution's database, found some apparently north-star-ish advice and made a clinical treatment decision. Luckily for the patient and them, the situation worked out for the best. They then conclude grandiosely:
Our case is but one example of a situation in which the existing literature is insufficient to guide the clinical care of a patient. But it illustrates a novel process that is likely to become much more standard with the widespread adoption of EMRs and more sophisticated informatics tools. Although many other groups have highlighted the secondary use of EMR data for clinical research,2,3 we have now seen how the same approach can be used to guide real-time clinical decisions. The rapid electronic chart review and analysis were not only feasible, but also more helpful and accurate than physician recollection and pooled colleague opinion. Such real-time availability of data to guide decision making has already transformed other industries,4 and the growing prevalence of EMRs along with the development of sophisticated tools for real-time analysis of identified data sets will no doubt advance the use of this data-driven approach to health care delivery. We look forward to a future in which health information systems help physicians learn from every patient at every visit and close the feedback loop for clinical decision making in real time. (Emphasis added)
These authors have identified a fundamental problem in clinical analysis - the volume of perplexing clinical questions supersedes the available volume of decent studies answering them. In this case, most clinicians revert to, what worked yesterday, or the day before. And clinicians with longer memories can go back even further. And those special clinicians with higher computing power can even figure out mental matrices in which they subdivide patients based on comparative characteristics.
But, of course, what these Stanford pediatricians have done is outsourced the mental computing to a local computer which does the hard work. And good for them and their patients. Perhaps the epidemiologists can figure out how to synthesize these datum to produce meaningful statements, similar to meta-analyses.
But clinicians shouldn't fool themselves or their patients into accepting that this is 'optimal' medicine. It's not. It's second best. Nor is this a problem if clinicians de-throne themselves from the alter of deities and begin to explain to patients the uncertainty in diagnoses and treatments.
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