One major strategy for managing uncertainty is seeking additional information about the likelihood of outcomes. New information may enable a patient to reduce their uncertainty directly, as when new research studies provide more insight into patient outcomes and suggest increase the likelihood that a particular treatment will or will not be beneficial. Even when new information does not yield greater certainty about outcomes, however, it may serve to narrow the range of the uncertainty.
The primary source of new clinical information is medical research. Most clinical research is explicitly motivated by a need to reduce the uncertainties around etiology, prevention, diagnosis, treatment, or prognosis.
Although research can extend our knowledge, the effective use of research for reducing clinical uncertainty is not always straightforward. For example, research conducted on the development of new drugs often results in adding a new treatment to the set of available choices that is not universally or unequivocally better than existing treatments. Consequently, this kind of research may actually increase uncertainty about the most appropriate treatment for a particular patient, while simultaneously decreasing uncertainty about the availability of a suitable treatment.
Moreover, the translation of clinical research to clinical practice faces several obstacles. First, the amount of new clinical research published each year is astounding and shows no sign of decreasing. As a result, merely keeping up with one’s field has become a more and more difficult process for physicians, particularly those who do not have ready access to academic medical libraries or online article databases.
In addition, not all research is equal. Many studies are beset with serious, and sometimes fatal flaws in methods or measurement, or greatly overgeneralize their conclusions. Conflict of interest among study researchers is not uncommon.
Evidence-based medicine, an approach advocated in academic medicine since the 1980’s, seeks to address these concerns by providing tools and training to permit physicians to focus their limited reading time on research that is methodologically strong and thus likely to yield reliable insights. The approach involves formulating a well-structured clinical question focused on such matters as the diagnostic value of a particular test or the expected outcomes of alternative treatments for well-defined conditions. Answers to these questions are sought in the medical literature. Individual studies are rigorously evaluated to determine how well the study responds to the clinical question that prompted the inquiry. This assessment considers soundness of research design, whether the findings apply to the patient of concern, trustworthiness of the conclusions, and limitations of the evidence. When multiple studies bearing on a question exist, EBM advocates the use of meta-analysis and systematic review to form overall conclusions.
Even when high-quality research has been performed, identified, and even codified in practice guidelines by professional societies, the results may not be widely adopted by the medical community. There are three primary obstacles to the adoption of new approaches that promise to reduce clinical uncertainty: lack of effective dissemination to practicing physicians, lack of comfort learning an unfamiliar regimen among physicians, and health care system impediments such as cost of care.
At the same time that adoption of proven improvements in medical care is slowed by the aforementioned difficulties, it has become easier and easier for Internet-savvy patients to obtain information about conditions and treatments – from both trustworthy and untrustworthy sources. Indeed, both the decreased time available for appointments under many health plans and the increased emphasis on patient autonomy in medical decision making exert pressure for patients to “do their homework”, often with limited guidance as to how to evaluate the information they develop.
Although pharmaceutical advertising is regulated in many countries, and physicians are familiar with marketing strategies used by drug companies, patients may not be as prepared to evaluate advertising claims for pharmaceutical products, much less for the larger group of unregulated supplements and alternative medicine products. Patients who are less well-educated may be at particular risk, and face a double jeopardy: less likely to have access to optimal care and less likely to be able to discriminate between safe and risky treatments.
The combination of slow dissemination of rigorously-evaluated medical advances among physicians and rapid dissemination of unscientific advice and claims among patients is a recipe for disaster. Public policy initiatives to improve health literacy among patients are an important strategy to avert catastrophe, but can not substitute for the impact of effective communication between well-informed physicians and their patients. Physicians can help their patients by taking the lead in explaining how medical research is conducted, suggesting sources of credible information that patients can use, and addressing the strengths and weaknesses of information from whatever source. Patients can help their physicians by learning how to seek out reliable information and bringing it to the clinical encounter with a critical eye.