Clinical Experience

I came in one morning to rounds and heard one of my classmates discussing his previous night on call. “Oh,” he said, “a woman came in, and we did such and such and such and such but luckily she died by morning.” What appalled me was that I understood how he felt: If she had lived, he would have had someone else to take care of.

Clinical Experience In addition to teaching doctors certain attitudes toward patients, medical culture also teaches—at a more abstract level—a set of attitudes toward medical care, illness, the body, and what makes humans truly human.

Ironically, given that doctors’ prestige rests partly on their scientific training, medical culture values clinical experience more than scientific research and knowledge. Students are routinely instructed to value their intuition and their professors’ clinical experience over the results of scientific research. At any rate, various reviews of modern medical treatments have found that fewer than half have good scientific support behind them. Similarly, when scientists rep- licate important research studies reported in prestigious biomedical journals, they frequently learn that the original results were in error: Drugs that appear to cure disease don’t actually do so, genes that appear to cause disease don’t do so, and so on. These errors can stem from mismeasurement, unconscious researcher bias, errors in statistical analysis, and laboratory contamination, among other things.

High-quality research supporting surgical interventions is even rarer. This partially explains why standard clinical procedure varies enormously  across the nation, producing high rates of medical error as well as rates of lumpectomies, prostatectomies, and back-pain surgery that are more than 30 times higher in some states than in others. Figure 11.2 illustrates these differences with regard to spinal fusions for back pain, a surgery with considerable risk but uncertain benefits: 13% of patients who receive spinal fusions require another surgery within 30 days.

Recognition of these wide geographical variations in medical care, combined with concern about rising costs of health care, have led policy makers (including some doctors) to push for the development of evidence-based medicine: medical care based on a thorough evaluation of the best available scientific research, especially research using random samples and appropriate statistical controls. Almost all medical schools now explicitly incorporate evidence-based medicine into their curricula.