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The Role of Experience in Science-Based Medicine

Before we had EBM (evidence-based medicine) we had another kind of EBM: experience-based medicine. Mark Crislip has said that the three most dangerous words in medicine are “In my experience.” I agree wholeheartedly. On the other hand, it would be a mistake to discount experience entirely. Dynamite is dangerous too, but when handled with proper safety precautions it can be very useful in mining, road-building, and other endeavors.

When I was in med school, the professor would say “In my experience, drug A works better than drug B.” and we would take careful notes, follow his lead, and prescribe drug A unquestioningly. That is no longer acceptable. Today we ask for controlled studies that objectively compare drug A to drug B. That doesn’t mean the professor’s observations were entirely useless: experience, like anecdotes, can draw attention to things that are worth evaluating with the scientific method.

We don’t always have the pertinent scientific studies needed to make a clinical decision. When there is no hard evidence, a clinician’s experience may be all we have to go on. Knowing that a patient with disease X got better following treatment Y is a step above having no knowledge at all about X or Y. A small step, but arguably better than no step at all.

Experience is valuable in other ways. First, there’s the “been there, done that” phenomenon. Older doctors have seen more: they may recognize a diagnosis that less experienced doctors simply have never encountered. My dermatology professor in med school told us about a patient who had stumped him: she had an unusual dermatitis of her hands that was worst on her thumb and index finger. His father, also a doctor, asked her if she had geraniums at home. She did. She had been plucking off the dead leaves and was reacting to a chemical in the leaves. The older doctor had seen it before; his son hadn’t.

Then there’s what we loosely call “intuition.” It can be misleading, but it can also be a function of pattern recognition that has not risen to the level of conscious awareness. Experience can help us perceive that “something just isn’t right” about a patient or a working diagnosis. An experienced doctor may get a feeling that a patient might have a certain disease. He couldn’t justify his hunch to another doctor, but he has subconsciously recognized a constellation of findings that were present in other patients he has seen. Of course, he would still need to do appropriate tests to confirm the diagnosis, but he might do more tests and do them sooner than a less experienced doctor. This kind of pattern recognition has been called the “Aunt Tillie” phenomenon: you can spot your Aunt Tillie’s face in a crowd, but you couldn’t tell someone else how to do it. You just know Aunt Tillie when you see her. Computer face recognition is learning how to do this, but it uses measurements, not the gestalt method our brains use.

Then there’s the wisdom that (sometimes) comes with age. I’ve just been reading Marc Agronin’s book How We Age where he shows that old age is not all bad. As we get older, we are not able to accomplish mental tasks as fast, and our short-term memory declines; but there are compensations. We are more able to integrate thinking and feeling, less likely to get carried away by emotions, better able to see both sides of an issue, and better able to cope with ambiguity. We can develop more patience, acceptance, tolerance, and pragmatism in dealing with complex situations. We have a vast store of life experiences to bring to the table, helping us put things into a more realistic perspective. Wisdom is elusive: not every elder develops it. I’m sure you can all think of many counterexamples.

Medicine is an applied science, and the same science can be applied in different ways by different doctors. There are times when two science-based doctors can look at the same body of evidence and still disagree about what it really means or about what to do for a specific patient. There is room for disagreement and for different approaches. Scientific medicine is often criticized for focusing on the disease rather than on the person who has the disease. I have known patients who have turned to alternative providers because of a bad experience with a science-based doctor’s poor communication skills or “bedside manner.” We can aspire to a kinder, gentler, more personal science-based medicine where experience and improving people skills are integrated with science (a kind of “integrative medicine” that actually makes sense.)

It’s not clear whether you are better off with a young doctor or an older one. A young doctor is more likely to be up to date on the latest science; an older doctor might make better patient-centered decisions. A younger doctor might be better at tuning up your bodily vehicle; an older one might be better at helping you decide when to drive it, where to go, and how fast. A young doctor might offer the latest treatment; an older one might question whether it is really preferable to an older treatment for that particular individual, or even question whether any treatment is really necessary at all.

Conclusion:

In summary, while “in my experience” claims can be dangerous, experience does have a role to play in science-based medicine.

Disclaimer:

As an ORF (Old Retired… something) and a Medicare-card-carrying senior citizen, I am biased. I have a vested interest in thinking that I have improved with age and experience. This is an opinion piece and I can’t cite any controlled studies to support my opinions. I’m almost tempted to insert tongue firmly into cheek and say “Trust me; I’m a doctor.”

Posted in: Science and Medicine

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24 thoughts on “The Role of Experience in Science-Based Medicine

  1. Irvin Bussel says:

    There is great value in a wide experience base in the applied science of medicine. The human organism is not a perfectly consistent system and medicine works to be generalizable to the majority. As such, diseases present in various degrees and symptoms in different individuals. Experience is crucial in being adaptable and comfortable with ambiguity. It is interesting to observe my fellow medical school classmates look for absolutes and even get infuriated when a process is vague or not clear cut. Perhaps my research background grants me the understanding to know better and appreciate the complexities.

    Absolutes statements and rules are easier to learn but they don’t translate so easily to clinical practice. The basic science years of med school seem to be about grasping fundamental concepts and developing an extensive vocabulary.

    This may be because I am but a young rookie in the game and still studying at 5am for my pathology exam but this quote seemed appropriate:

    “Beware of the young doctor and old barber”. – Benjamin Franklin

  2. Thanks Harriet Hall, this is lovely.

    My mother died yesterday morning of multiple myeloma at age 66. Her hematologist was young and aggressive. He thought his job was to keep her alive as long as possible. When she eventually decided she was refusing treatment he came and told her (paraphrased) that he fully understood her decision to give up.

    Older docs were more honest about how bleak the future was likely to be and we didn’t get the same “you’re giving up” vibe from them.

  3. Scott says:

    I agree, experience definitely has its place. The problem arises when experience is used as an excuse to skip doing proper science. Or worse yet, is claimed to actively trump the proper science, a la Jay Gordon.

  4. Valic says:

    Experience definitely has its role in any profession, however it seems that older docs get complacent or are not used to being in an information age where research is being published in droves.

    Here is a relevant reference: http://www.ncbi.nlm.nih.gov/pubmed/15710959

    “CONCLUSIONS: Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians may need quality improvement interventions.”

  5. windriven says:

    One person’s ‘experience’ is another’s wild speculation. Dr. Hall hit it squarely when she said, “[intuition] can draw attention to things that are worth evaluating with the scientific method.

    Medicine is still a relatively incomplete science. Much is known. Much is not. Disease doesn’t always wait for the breakthroughs in science that lead to cures. Experience is what matters when science based medicine reaches the end of its road.

    As a patient, one can choose the experience of a physician whose practice has been informed by science or a quack whose experience is with qi and chakras. (Or one could go to a Mehmet Oz and have the worst of both worlds.)

  6. nybgrus says:

    Funny, I just had a conversation with my girlfriend over dinner about this topic and an idea for an opinion piece in which a large part would be exactly this discussion. Maybe I better get cranking!

    It is also funny because just today I got into a bit of an argument with some classmates today who were having trouble coming up with a diagnosis and the importance of some findings. The case in question was a man in his 60s who never saw doctors (hated them) and had developed a lobar pneumonia. After the diagnosis was settled by chest xray the question of significance of his non-healing purulent leg wound was. The most junior members asserted that since he was quite ill he met the criteria for sepsis. This, they asserted meant he must have bacteremia and thus the offending organism must have come from his leg wound. This seemed patently ridiculous to me and I said so to which I was told “I am sure that sepsis means you must have SIRS with bacteremia. I’d bet a lot on it.” I didn’t have the definitions handy, but I didn’t need them (or so I thought). I commented that if the cause were indeed bacteremic spread from the leg to the lungs it would be highly unlikely to be a lobar pneumonia (which it clearly was based on CXR). No, it was insisted that I was wrong and that the purulent leg was an important clue to the pneumonia and that empiric treatment for Staph aureus should commence. Finally looking up the definitions I showed them to be wrong and then of course the cultures results confirmed what I had been saying.

    The point is that the ones so certain and unquestioning had entered medical school after only 2 years of undergrad and had never seen an actual patient before. I’d seen heaps of elderly pneumonia patients in my few years at the ER and not only did the diagnosis come much more quickly to me, but the crazy tangents my (much) younger colleagues went on were not something I was so prone to do. It seemed to me that they were looking for every scrap of information to fit what they’d read in the textbooks and there was an urgency to fit every detail into a neat framework. But medicine is more than just applying what you know – it is coming up with the best answer when you don’t know everything (which is always). And being satisfied that a detail is not salient and content to leave it alone. So Irvin – I see a lot of that as well. The human brain seems to crave absolutes.

  7. tuck says:

    Wonderful post.

    I’ll put in a big vote for experience. And a smart individual will keep up with the latest research.

    I had a surgery a few years ago where my 50-something doctor explained to me how the latest findings from combat surgery in Iraq changed how he treated my condition.

    The best of both worlds. Using his new techique, I fully recovered in 2.5 days.

  8. Alison Cummins – That is very sad news. I am so sorry for your loss.

  9. Harriet Hall – Excellent piece. One of my favorite kinda sciency reads is Blink by Malcolm Gladwell. In one chapter he talked about the intuition that people highly skilled in a particular field develop. You describe the phenomenon very well with your Aunt Tillie analogy.

    As a generalization that has many exceptions, In my experience I prefer middle age doctors…somewhere between 40 to 55, although I generally guess low on people’s ages…

    Very young doctors may be enthusiastic and up on the latest, but they sometimes are lacking in people, communication skills, they often talk way too fast for my middle aged brain to process and well, they do sometime do just seem to lack gestalt. It also seems a young doctor if more often less likely to see or admit their mistakes than a middle age one.

    My experience with older doctor’s (over 60ish) is somewhat limited, I think I’ve only had two. They were not good experiences. I felt they were both over confident, somewhat behind in their field, technically and just kinda had a “I know better than you” attitude. On the other hand, two is not a good sample size. ;)

    Just as an aside, Since we use a teaching hospital for my son’s care, we meet many interns/residents. When we go for a specialist consult, they usually send in the intern(s) first before the specialist. My husband and I have a running joke that they must make the interns/residents check their personality at the door upon signing up for the internship. I mean they are all nice enough…but they are like the Stepford doctors. I think one is twenty has an actual distinctive personality. Of course I can’t complain, there are alot worse problems, but what do they do to these poor med students, is it sleep deprivation, youth, just trying to be polite, brainwashing?

  10. jpmd says:

    Great post. As a 57yo doc, I can agree with pretty much everything, and often self reflect on where I am as a doctor. I hope I recognize when it is time to hang it up, and as much as I hate board recertification, it does give you a yardstick by which to measure yourself in comparison to your peers, at least cognitively.

  11. colli037 says:

    I agree, very nice post. Experience based medicine and Eminence based medicine should be viewed with skepticism.

    I used to work in a small town solo practice, but now I’m at a university based practice. Its really interesting to look at referral patterns (referral bias) and my “experience” with certain problems like headaches.

    As others have said above, some of the training is to get us aware of the more common problems, and think of them first (as most docs have heard, “when you hear hoof beats, think of horses, not zebras”.

    micheleinnmichigan–I think interns/residents have no personality mostly because their too scared of saying the wrong thing, or too worried that they will forget to ask the right question or miss something. I’ve worked with residents for the last 10 years, and they actually have more personality after the first 1-2 years as the get comfortable with the process.

    Working with a medical student with a personality is a treat, usually they are so overwhelmed that they can hardly think.

    tim

  12. Mark Crislip says:

    I use the phrase in the context of treatment, not diagnosis.
    Experience has made me a better diagnostician every year. Few things are more frightening to read than notes and consults from your first few years in practice. I have, and wonder, just who was that ignoramus?
    I live in fear of the day the housestaff roll will their eyes when they see me coming down the hall. Well, they do now, but not because of my lack of medical skills. I think.

    I would see a doc who has been in practice 10 to 20 years. Past the rookie phase and before the inertia sets in. Except ID docs. Like a good wine, they only improve with age. But be esp wary, at any age, of neurologists, FP’s, cancer surgeons, anesthesiologists, pediatricians, and general internists :)
    Next post: How to win friends and influence people.

  13. GLaDOS says:

    …just who was that ignoramus?

    You mean, it stops? The surprise at how blind or stupid you were just a few years ago?

    I kinda figured I’d hit the mark of deep understanding of the human condition about a week or so before the massive stroke that does me in. Seems to be the way of things.

    Sorry about your mom, Alison.

  14. Kultakutri says:

    Allison Cummins: sorry for your loss

    Mark Crislip: I guess I want to have you at home to entertain me. You’re right on the notes. I don’t read my first drafts for the same reason, they’re scary.

  15. colli037 – well I’m glad that my hospital isn’t taking the sleep deprivation of the interns/residents as an opportunity to engage in personality reprogramming experiments. ;)

    Yes, What you describe is, I think, what I’m picking up on. It’s not so much that they never have a personality, it’s that they’re a little bit socially not present, while they are super-focused on figuring things out and “getting it right.”

    I can relate to that.

  16. DBonez5150 says:

    Allison Cummins: I’m sorry for your loss too. My mother is 62 and in the mid stages of MM.

    I had a similar experience with a new doc versus an older, experienced cardiologist. When my young wife was in the ICU dieing of some, at that moment, unknown disease, I was consulted by her hospitalist and cardiologist. The young hospitalist was nervously showing me a CT explaining that they thought they knew what the three “circles” in her liver were, but needed to run more tests prior to saying what they suspected it was. I was quite confused and distraught that my 35yo wife was crashing, in renal and hepatic failure, and had repeated pleural effusions just a week after being admitted. A few minutes later, her cardiologist called me into the hallway and explained he had seen this before and that the transected circles were tumors and it was cancer with a poor prognosis. Despite the horror of the diagnosis, I was relived to finally have some information to move forward with. The cardiologist was right – she died a few weeks later.

    Which doctor was right with their explanation? I don’t know. For me, the cardiologist did the right thing. For a different person with a different point of view, maybe the hospitalist was right to not jump to conclusions without a more conclusive diagnosis and prognosis. It took another full week for the tumor board to diagnose the specific cancer and by that time, my wife could no longer communicate. The cardiologist gave me an extra week to communicate with her with the knowledge of her condition. What if he had been wrong? I don’t know – he wasn’t.

    My primary care doc is wonderful with explaining things and giving me several options for treatment. I then go and do some research (doctor buddy’s, U of Google, etc.) and email him with the meds I want or treatment I prefer. He doesn’t do that for many of his patients, but we have a good relationship.

  17. michaelangelica says:

    Nice, I liked especially the description of my mind in old age.

    Science based medicine is more of an idea than a reality.
    Perhaps a nice thing to strive for and not always, if even often, achieved.

    Witness the recent difficulty US hospitals have had getting doctors to wash their hands.
    Surgery is rarely put to the test. If it is, it is frequently seen as ineffective and sometimes even dangerous.

    This article in ‘Scientific American’ highlights some of the problems
    http://www.scientificamerican.com/article.cfm?id=demand-better-health-care-book&WT.mc_id=SA_WR_20110330

    I suggest that poor septics will have to accept that the “art’ of medicine will always contain a bit of Voodoo and magic. Something we seem, apparently, to pick up by ageing.

    1. Harriet Hall says:

      @michaelangelica,

      “poor septics will have to accept that the “art’ of medicine will always contain a bit of Voodoo and magic. Something we seem, apparently, to pick up by ageing.”

      NO. That is not at all what I meant. Neither septics nor skeptics accept that.

  18. Artour says:

    When I teach my students (or patients), my experience allows me to suggest to up to 80-90% of them that they will be free from medication and symptoms related to asthma, sinusitis, CFS, bronchitis, primary hypertension, eczema, panic attacks, and some other conditions, if they devote about 1 hour per day for breathing exercises and 1 hour for easy physical exercise with nose breathing only.

    This confidence is based on the fact that chronic diseases have low body oxygen levels as their key factor, and breathing retraining eliminates the foundation of their problems. As an evidence or an a theoretical level, presence of chronic hyperventilation that causes tissue hypoxia in the sick is a solid medical fact:
    http://www.normalbreathing.com/i-hyperventilation-syndrome.php

    Hence, if the cause is eliminated, then the effects will disappear.

    1. Harriet Hall says:

      @ Artour,

      You failed to understand my message. You provide a good example of the kind of experience that Dr. Crislip appropriately described as the 3 most dangerous words in medicine.

  19. Chris says:

    And yet, Artour, that method can cause an abortion! Everything can be accomplished with just proper breathing.

    Yeah, your spamming is annoying.

  20. GLaDOS says:

    Dr. Hall,

    Your spelling methodolatry cannot contain the art of medicine, nor can it contain the laughter of a child or the wisdom of a long life well lived. Therefore homeopathy is true.

  21. Harriet Hall “NO. That is not at all what I meant. Neither septics nor skeptics accept that.”

    Well, he did say “poor” septics (skeptics). We still don’t know what good skeptic will have to accept.

  22. billga says:

    Personal experience is limited, seldom recorded and imperfectly and perhaps selectively remembered. As we approach EHR as the dominant method of recording clinical events we can create collective experience on a local institutional, national or even global scale. In some cases this is already happening and is the true model of how experience can contribute to scientific healthcare

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