May 19th is peanut free day at the Indianapolis Indians ball game. What better way to end food allergy awareness week.

Food Allergy Support Indianapolis (FASI) formerly known as PoCHA has helped sponsor this event. We are now in our 3rd year.

This event will be so peanut free that the song that is traditionally sung during the 7th inning stretch (Take me out to the ball game) will not even contain peanuts!

Join FASI and the Indianapolis Indians for a safe and fun evening.

FEL 5/16/2017

Physicians Practice is one of those many journals that finds itself on my desk. I usually browse through the articles while enjoying a quick lunch. I am on the subscriber list due to my connection with the Indiana University Medical Group. The journal deals mostly with practice management which is great for someone in private practice. In February of this year Physicians Practice did published a case report that I wrote. The case involved the critical role allergy has in asthma diagnosis and management. For the most part this journal has articles about electronic medical records, coding, dealing with health insurance companies and so on. Many of these topics are interesting, but do not have a direct impact for someone working in an academic center. However, the April edition of Physicians Practice has a very interesting article (page 26) on ‘Evidence-Based Medicine’. The attention getting statement certainly made me take a look, “Evidence-based medicine has been around for 16 years. So why are some physicians still resistant to it? And how can you make it work for you?”

Evidence-based medicine (EBM) tries to provide a framework for treatment that is supported by the latest proven research. The article talks about this enhancing a medical practice. I think that patients and families should be aware of EBM. I can see value of EBM in the practice of allergy by board-certified allergists especially in an environment where the label of ‘allergy’ is given too loosely. In my practice I am seeing conditions labeled as allergy (apraxia, autism, sensory integration defects, ADHD to name a few) because tests for allergy return as positive. Many times the clinical condition and the test has nothing to do with allergy. IgG to food would be a prime example. I have seen significant amounts of money spent and hopes of families dashed by the use of tests and therapies that are not evidence-based.

The EBM approach first asks a very specific clinical question. The question could be about a test, a treatment, a diagnosis, or an outcome. Next the literature is searched for information on the topic. The information is then evaluated to see if it is valid, useful, and related to the question. The review of the literature looks critically at many different aspects of the scientific studies. The numbers, the methods, and the statistics are evaluated. The EBM may conclude that there exists type A evidence (great supportive studies in a large number of patients) that a treatment is effective.

Other support for diagnosing and treating can be found in ‘Guidelines’ . Many specialty organizations offer guidelines for common clinical conditions and the guidelines will incorporate EBM.

Resistance to EBM stems from concerns that it is a cookbook approach to medical practice. Another issue is how can a busy practitioner  integrate EBM into a practice. The article provides ideas and links for the practitioner.

Now the journal also had an excerpt from an article written by D. Isaacs and D. Fitzgerald that appeared in the British Medical Journal a few years ago (BMJ 1999;319:1618) that poked a little fun at EBM. What follows was the results of a poll that asked physicians what they would do if there was no solid evidence in the literature to help with a clinical decision. The article was titled, “Seven alternatives to evidence-based medicine”. This made me smile.

1. Eminence Based Medicine- The more senior the person, the less need for evidence. Experience outweighs evidence. Faith in clinical experience was defined as making the same mistake with increasing confidence over an impressive number of years.

2. Vehemence Based Medicine- Substituting volume for evidence as an effective technique for brow-beating a more timid colleague.

3. Eloquence Based Medicine- The perennial sun tan, carnation on the Armani suit, the silk tie accompany a tongue as equally smooth. Tailored eloquence and verbal eloquence are powerful substitutes for evidence.

4. Providence Based Medicine- If the caring practitioner has no clue what to do next, the decision may be best left in the hands of the Almighty.

5. Nervousness Based Medicine- The fear of litigation is a driving force for more tests and excessive treatments.

6. Confidence Based Medicine- Restricted to surgeons

Now I am puzzled- the quip in Physicians Practice said seven, I count only six. This second article ended and I could not find that seventh alternative. Finally, I found the original article at the Ruth Lilly Library on OVID. Here is number seven.

7. Diffidence Based Medicine- Some doctors see a problem and look for an answer. Others merely see a problem. The diffident doctor may do nothing from a sense of despair. This, of course, may be better than doing something merely because it hurts the doctor’s pride to do nothing (BMJ, 1999).

That was the original article on alternatives to EBM. Now it gets even better. Others have added to this list, we now have the following alternatives; Effervescence Based Medicine, Webidence Based Medicine, Profit Based Medicine, Annoyance Based Medicine, Propaganda Based Medicine, and Arrogance Based Medicine to name a few. We see a significant amount of Webidence Based Medicine. I urge caution with the internet. Look to sites sanctioned by well known organization- the American Academy of Pediatrics, the American Academy of Allergy, Asthma, and Immunology, the Food Allergy and Anaphylaxis Network, the National Institutes of Health, the National Heart, Lung, and Blood Institute to name a few. Profit Based Medicine – as a personal word of caution, ask about insurance coverage. Your insurance may not cover something because it is experimental or without EBM to support what is done. There is usually a reason why something is not covered by insurance. Ask about it.

I do my best to abide by evidence- based medicine. It makes sense to me. Evidence for my diagnosis, evidence for my selection of tests to help with that diagnosis, and evidence for the best treatment for the condition. Medicine is changing all the time. EBM helps evaluate what we have done and helps to consider what we need to do for the benefit of those we are taking care of.

Fred Leickly