Evidence-based medicine

Abstract

Mark T. Metzdorff, MD, Western Trauma Association president.We hear a lot these days about the concept of “evidence-based medicine.” Six years ago, one of our most illustrious and intelligent presidents also made it the subject of a presidential address1. I will cover a little of the same ground, but bear with me and we will sail into some different seas, as I will address the use of non–evidence-based medicine in some aspects of modern medical care, rather than the exciting possibilities that Fred Moore described. I think we all have an idea of what evidence-based medicine means to us personally, but in fact, there is a definition that is accepted by some major organizations devoted to the study and promotion of the concept, and there is a large body of work by these organizations and others around the topic. “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”2 This relatively recent definition implies that the concept is modern, but look at the key word current, and one can see that the concept can be said to be timeless, for what is current changes as our knowledge base changes. To me, one of the things that is interesting about this concept is how physicians have practiced evidence-based medicine through the years. To illustrate this, I would like to take you back to the time of the Napoleonic wars, at the turn of the 19th century, when the English Royal Navy battled for the control of the seas. Some of you may be familiar with a series of novels by a wonderful author of historical fiction named Patrick O’Brian. Between 1970 and 1999, O’Brian produced the 20-book series, which aficionados call “The Aubrey-Maturin Series”3 (Fig. 2). Those not familiar with the books may have experienced a small taste of O’Brian’s world through the movie adaptation “Master and Commander,” released in 2003. The movie was an amalgam of several of the books, with small and larger pieces taken from them. The twenty books are chronological and span about 13 years of history, in which the characters experience global events as they sail around the world in the course of their duties. There are dozens of memorable characters and plot lines, which ebb and flow throughout the books, and there is incredible attention to details of the historical settings, the natural landscapes and seascapes, and the depictions of life at sea and on land in the time of Lord Nelson and Napoleon, and in the aftermath of the American Revolution. I commend these books to anyone who loves a good story, for they are as entertaining as they are informative. Patrick O’Brian created a masterwork at a level with the best historical fiction ever written and has been rightly celebrated for it.Figure 2: The Aubrey-Maturin Series, by Patrick O’Brian.Most people who have seen the movie assume that Captain Jack Aubrey of the Royal Navy, the character played by Russell Crowe, is the main protagonist. However, in the literary series, there are really two coequal protagonists. The second and to my mind much more appealing and interesting character is Jack Aubrey’s dearest friend, Dr. Stephen Maturin. Of course, he is a surgeon! In fact, he is much, much more than a mere surgeon: He is a physician in the 18th century sense who treats all ailments, a naturalist who is a member of the Royal Society and regularly presents his work at Society meetings, a polyglot who speaks six languages fluently and is conversant in four others, a passably good cellist, a superb swordsman, a statesman, a gentleman, and a spy for the British Admiralty, and he is an absolutely inept sailor. He mangles the nautical names of the ship’s components and cannot pass between the dock and the ship without falling in the drink. Thus, he is constantly looked after in this regard by his shipmates, who rightfully value him as a particularly renowned ship’s surgeon and a man who might someday save their lives. Stephe