Lies, Damn Lies, and Statistics

The editor reflects on the dichotomy between evidence-based medicine and individualized patient care, as exemplified by two former roommates embodying "left brain" and "right brain" approaches to medical practice. The narrative delves into the complexities of adhering to clinical guidelines while recognizing the limitations of population-based recommendations in addressing individual patient needs. Emphasizing the importance of evidence-based practice, the Editor navigates the nuanced balance between guidelines and clinical judgment, advocating for their judicious application within the context of patient-centered care. This introspective journey underscores the dynamic nature of medical decision-making and the ongoing quest for optimal patient outcomes amid evolving clinical paradigms.

I used to call them the Left Brain and the Right Brain. They were my two roommates at the student housing during one of my remote rotations. Lars, the Right Brain, was in med school as his second career and although he was quite bright, stunningly talented at OMM and a great listener, he resisted rote memorization of pathogens and algorithms so much that although it was our fourth year, he had yet to pass Step 2 of the boards. Tim, the Left Brain, was a delightful and friendly person who listened to Audio Digest for fun and would joyfully jump in and do the blood draws at the clinic if the MA was too busy. It was from Tim that I first heard about the JNC. Specifically, he came back to our shared apartment upset because his attending was not adhering to JNC-6 guidelines about spironolactone in CHF.

While I was trying to play it off as though I even knew what “guidelines” Tim was talking about, Lars hurtled in to the discussion defending the attending: “Patients are human beings! Not numbers! We practice according to what is best for the patient, not according to what some committee tells us! One size does not fit all!” Tim, also a patient-centered kind of guy, nodded in agreement, but added, “We do need to practice according to the evidence, not just according to what the guy before us always did. Isn’t that a better way to provide care?”

Both are great people and neither was wrong. And all of us experience an internal battle of the brain hemispheres when practicing medicine. After JNC-7, we followed the guidelines, got all our patients’ blood pressure to target, and felt great about it until our preload-dependent seniors started hitting the floor. That’s “left brain” medicine gone awry. On the flip side, how many of us ignore the large body of evidence in support of amiodarone for certain dysrhythmias because we are haunted by that one patient whose nose turned purple and stayed that way? Our intuitive, gestalt-driven right brain can reactively put us on the wrong path as well.

Guidelines do a great job of predicting what an intervention will do to a population, but not to an individual. As my pulmonology attending used to point out, “Even if it’s a rare side effect, if it happens to you, it’s 100%.” Another mentor, however, would assert, “The plural of ‘anecdote’ is not ‘data’.” Yet this same mentor was also fond of quoting Mark Twain on the three kinds of lies: “Lies, damn lies, and statistics.”

We do have a responsibility to practice according to evidence, not intuition, and however some of us may flinch at the notion of applying a treatment algorithm to a human being, we are really fortunate to have review bodies like the JNC and the US Preventative Services Task Force to sift through the enormous amount of evolving data so we don’t have to. We also need to understand the way the conclusions are drawn and know their limitations as applied to certain individuals. To quote yet another mentor, “this is why medicine is hard.”

In this issue of OFP, we offer an update of the JNC-8 recommendations on blood pressure. You may be happy to notice that the targets for seniors have relaxed a bit. Inevitably when new guidelines are released, someone points to the change as proof that they were “wrong” the last time, and some will take it a step further and bemoan the uselessness of these committees because “they keep changing their mind so what good are they? I’m just going to keep doing what I know works.” I disagree. Guidelines are not the Ten Commandments or the Magna Carta, static instructions to be followed no matter what new information comes through. They were never intended to replace good judgment. Guidelines are a tool, and just like any tool, it’s important use the best one you can find, but to use it appropriately and within its scope: no matter how terrific your new screwdriver is, you don’t use it to make an omelet. And if you try to anyway, the ruined breakfast will be your failure, not evidence that it was a lousy screwdriver.

Almost 15 years later, I periodically run into both Lars and Tim. They both remain intelligent, kind people and both seem happy with their lives and their choices. It is worth noting, however, that Tim is a beloved Associate Dean who just received a national award for excellence in education. But although he did eventually pass his boards, Lars no longer practices medicine at all.