Applying Science-Based Medicine: What to Keep in Mind

One of my areas of interest is science-based medicine (SBM), an approach to medicine based on the best available science, using information from double-blind, placebo-controlled trials that are as methodologically sound as is possible, while understanding the limitations of applying these results to broader and divergent clinical populations. 

This is the classic dilemma. We have access to solid information from well-done studies on a small group of patients who cleanly meeting the DSM criteria for a specific disorder. These carefully screened participants have few or no comorbidities, take few or no other confounding medications, and do not use/abuse nicotine, alcohol, recreational drugs, etc. These are great data, largely (but never completely) free from biases and confounding variables—but they describe a group of patients who look almost nothing like the patients most of us take care of on a daily basis.

We also have access to the “Encyclopedia of My Experience,” a wealth of our individual perceptions of both cross-sectional and longitudinal data based on “real-world” patients, also subject to our own recognized and unrecognized biases, beliefs, and preconceptions.

Practicing “by the book” makes good sense; however, to the extent that our individual patients are dissimilar to the study population, the predictive value of the outcome data from the study becomes less powerful.

So what is a reasonable clinician to do?

My educated guess is that the truth is likely somewhere in-between, not precisely in the middle, but somewhat closer to the clinical trial data. In my own struggles with this dilemma, I have found it helpful to keep the following tenets in mind:

1. The plural of anecdote is anecdotes, not data.
2. Extraordinary claims require extraordinary proof  (philosopher David Hume).
3. The three most dangerous words in medicine are “in my experience”.
4. Even a broken clock is right twice a day.
5. Size (as in N) matters.
6. Not all journals are created equal.
7. If the only tool on your belt is a hammer, eventually everything begins to look like a nail (psychologist Abraham Maslow).
8. The most exciting phrase to hear in science, the one that heralds new discoveries, is not “Eureka,” but “That’s funny…” (biologist and science fiction writer Isaac Asimov).
9. That which can be asserted without evidence can be dismissed without evidence (author Christopher Hitchens).
10. The first principle is that you must not fool yourself, and you are the easiest person to fool (physicist Richard Feynman).

To what extent (if any) do these principles of SBM guide your practice?

Chris Bojrab, MD, is the president of Indiana Health Group, the largest multidisciplinary behavioral health private practice in Indiana, established in 1987. He is a board certified psychiatrist and a Distinguished Fellow of the American Psychiatric Association who treats child, adolescent, adult, and geriatric patients. His areas of interest include psychopharmacology, sleep disorders, and gambling addiction. For more information and disclosures, visit www.chrisbojrabmd.com

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The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors.