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The Awkwardness of Evolving Evidence

by Anne Meneghetti, MD, Executive Director of Medical Information, Epocrates

If you’ve been in practice long enough, you’ve heard patients question changing, sometimes contradictory, recommendations:

“My older son didn’t get this vaccine, so why does my younger son need it?”

“My other doc says my blood pressure is just fine for my age.”

“But my gynecologist insisted that I do need a Pap this year.”

When clinical evidence evolves, or experts differ in their interpretations, it can make some patients question if we know what we’re doing. As the teenagers in my life would say, these patient conversations can be “hashtag awkward.”

Bias in an Evidence Vacuum

Even as new evidence comes to light, or old evidence gets a fresh look, clinical experience continues to play a strong role in decision-making. When I turned 35, my personal physician recommended a “baseline mammogram” – a concept foreign to young clinicians today. I declined, citing the lack of statistical evidence. My doctor paused, lowered her voice, and said, “Evidence or not, I recently had a patient die of breast cancer at age 27.  It was devastating.” Despite her plea, I declined again. What I didn’t share with her was the real reason underlying my refusal: A young relative of mine had her breasts turned into pincushions from biopsies almost every year, chasing shadows seen on annual mammograms, and each year she’d receive the news that no cancer was found. Over the years, I continued to seek evidence on breast cancer screening that would validate my personal choice as a patient. The ultra-skeptical US Preventive Services Task Force was like a friend in that regard.

When there’s a relative evidence vacuum on a controversial topic, as is the case for breast cancer screening, expert recommendations urge a frank discussion between clinician and patient to consider the latest scientific evidence and uncertainties, as well as tailor individual risk factors, benefits, and harms - all in keeping with the patient’s personal values. That’s a mighty tall order for a short office visit.  This challenge inspired Epocrates to explore the landscape of varying guidance from leading specialty societies and the evidence behind each one.

Making Sense of Current Recommendations

The Epocrates clinical team analyzes and distills guidance from major medical specialty societies and government agencies on controversial topics, and packages it into a 90-second experience that clinicians can use in the moments of care. Our innovative patient-type tier format means that once you identify the characteristics corresponding to the patient in front of you, you’ll see a set of practical, actionable guidance steps for that patient. Compare and contrast the varying recommendations from multiple medical societies and agencies at a glance.

Beyond our continually updated breast, prostate, and cervical cancer screening topics available in the Epocrates mobile app, we’re tackling the topics that most often bring patients to clinicians, inspired by data from the athenaClinicals EHR. Let us know which topics you’d like to see covered in our growing guideline synthesis library.

The Future of Evidence

For many controversial topics, the perfect clinical trial will never be done.  The perfect evidence will continue to elude us. As more EHRs become as interoperable as the athenaClinicals EHR, the promise of a securely aggregated massive patient dataset becomes real. Outcomes studies from a vast dataset could serve as an antidote to biases like the ones held by my former personal physician and my 35-year-old self. At the very least, such data could signal directions for targeted prospective studies. As evidence evolves, Epocrates guideline syntheses and athenaClinicals point-of-care clinical decision support will continue to make the moments of care a little less awkward.

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