They talk a bit about clinical judgement in this short paper and how EBM doesn’t allow practitioners to exercise their judgement as often. I find this interesting, and wonder if in Australia they practice medicine fundamentally differently than in the US. In the US, it seems, EBM is the defacto winner. So much so, in fact, that if you aren’t responding to what EBM says you should be, many practitioners are entirely unwilling to go outside of clinically recommended norms. This becomes particularly problematic when standards are set by a very small number of studies.

A very good example of this which has pretty low stakes is body temperature. We’ve established for some time that 98.6F is the ‘normal’ body temperature and from this range we’ve derived what a ‘sick’ state looks like (fever >99F, etc.). The problem is, that many individuals do not normally sit at 98.6F, and is basically derived from a single study. So we consistently ask patients if they have a fever, we give them guidelines for what a fever is, and we set protocols based on these values which do not reflect every patient. Rather than establishing a baseline for patients and then setting potential states above (and below!) normal range as a probable cause of fever, we end up missing many clinical indicators because of insignificant EBM. Where this has actual stakes is when we derive entire states of disease based on one factor the vast majority of the time, examples include hormonal problems, certain kinds of infection, and more.

This also becomes particularly problematic in rare disease states and in minority populations which do not have a lot of evidence based medicine. Transgender healthcare, for example, affects many millions of people in the world (some estimates put the incidence rate of transgender individuals as high as 1 in 100) and yet the amount of clinical evidence we have for regular care is often surprisingly little. Much of the EBM that is used is actually inferred from cisgender populations, such as those with hormonal issues and what ranges worked for them to restore a sense of normalcy or inferred from intersex and individuals in a disease state and what ‘fixed’ the problems they experienced. Because of this many doctors who treat these individuals are unwilling to offer the care the patients are asking for in many cases (because there is insignificant EBM or it goes against EBM guidelines). These patients are often asking for care because they have become experts by spending their time learning the biological background of their condition and in communities of similarly effected individuals sharing knowledge on what worked on an individual basis. When they go to a doctor to ask to try out different medical interventions to see if any particular one might be of benefit to them, they are often met with dismissal or denied treatments because of EBM.