Clinical Jazz

I felt these few paragraph really make sense

Clinical Jazz

"Jazz is a music genre that originated amongst African Americans in New Orleans, United States, in the late 19th and early 20th centuries. Since the 1920s jazz age, jazz has become recognized as a major form of musical expression. It emerged in the form of independent traditional and popular musical styles, all linked by the common bonds of African American and European American musical parentage with a performance orientation.^[1] Jazz is characterized by swing and blue notes, call and response vocals, polyrhythms and improvisation"

If EBM were solely medical decision making based on evidence, it would become what critics call cookbook medicine, and could be done by computers. Either that, or we'd be paralyzed, unable to care for patients at all because there just aren't valid POEM data for much of what we do. Yet if we practiced only experience-based medicine, we may still be bloodletting our preeclamptic patients because some of them got better. Lest we consider this an unrealistic example, how many of us are victims of the latest bad experience bias? Objective evidence of this bias is seen in obstetricians whose cesarean section rates increase following an adverse event.²³ Clinical experience is important, but as the sole evidence source it is fraught with biases that would never be acceptable if presented in a research article: small sample sizes, lack of blinding or randomization, lack of standardized outcome measurements, and nonrandom loss to follow-up.

EBM is not really in competition with clinical experience. The newer definition of EBM integrates the use of evidence, balanced with clinical judgment and the patient's preferences. In the IM model, this is clinical jazz. And like fine jazz music, it requires structure—the evidence of valid POEMs—along with improvisation—our clinical experience. Following this structure can actually be liberating. Basing our decisions on well-done outcomes-based research helps us avoid being ping-ponged between conflicting recommendations and may increase our confidence with medical decision making. The simplicity of the structure allows us ample room for improvisation. We use our judgment every time we make a decision in the absence of ideal evidence: POEMs with study flaws, or valid DOEs, or no existing evidence addressing our clinical questions. A key component of EBM in these situations is the awareness that our decisions are based on this lesser-than-ideal level of evidence and keeping our eyes open to replace that information when better quality data are available.²⁴

Conditions with multiple valid POEMs, such as hypertension, provide opportunities to improvise as well. We rely on our clinical experience to apply most research data, since the patients we see in our offices are rarely as healthy, nor is our follow-up as rigorous, as those in randomized controlled trials.

Finally, our artistry and communication skills are needed to negotiate with patients whose preferences differ from the evidence. One patient may refuse colon cancer screening, despite high-quality relevant data in support of flexible sigmoid-oscopy; a mother may demand a computer tomography (CT) scan to evaluate her child, who has an acute headache but a normal exam and evidence demonstrating no need for a CT scan. A restricted view of EBM would suggest we only perform those services with evidence to support them; patient-centered medicine may seem like bowing to the patient's wishes regardless of the evidence. Clinical jazz is harmonizing the evidence, our experience, and our patients' views together to come to a reasonable decision. This is a true evidence-based medical practice!