Clinical Practice: Evidence Based Medicine in the age of Big Data

Evolution of medical practice

Despite what it may appear, many of us in the field believe that the practice of medicine has changed very little over time, and rightly so, though this may outrage some.

The basis of our practice is still the careful observation of the patient, combining what the patient says with what we are able to see and perceive during our examination, which allows us to determine a diagnosis where possible, and prescribe a treatment or care plan.

After this initial stage, we continue observing the patient to verify that the ir progress is going according to our previsions – which we have established based on our acquired knowledge – or whether there are unforeseen variations.

In the past, and not unlike today, the difference between the qualities of physicians was determined by their skill in patient history taking, classification and correct interpretation of patient information that provided a proper conclusion, or diagnosis.

We acquired knowledge and practice in Schools where the observations of our predecessors were deposited and wise men evaluated their accuracy and suitability. They then verified that these observations were carried out correctly and that they corresponded either to a known disease, or they were unique enough to determine that they corresponded to a new illness or disease.

In this manner we have incorporated observations that either consolidate, amend or reject claims and previous paradigms. And in such a way, sometimes more slowly and sometimes times more quickly, we have come to acquire today’s medical knowledge.

Despite this, we were still in our own “Little World”: There were very few Medical Schools, which allowed us to know their strengths and weaknesses. The number of textbooks was also limited and new editions that included “advances” in medical knowledge were published with several years delay.

The scientific journals that published the findings of other doctors with less frequency than books, were a manageable number. And although this new knowledge was made available to us, we still needed time for our own observations to validate these advances.

The Technological Revolution

And in the middle of this came what was so aptly called the “Technological Revolution”, where, much like Energy was the basis of the First and Second Industrial Revolution, Information was the essential raw material of this one. The main characteristic of this new essential raw material is that it is based on a series of scientific discoveries that affect PROCESSES more than products; that is to say, the complete opposite of the previous revolutions.

In the Preface of the first edition of the book New Technology, Economy and Society in Spain by Professor Manuel Castells, he skillfully summarizes the significance of this Technological Revolution paraphrasing a famous manifesto that shook the 20th century. It says the following:

“A new specter is haunting the world: new technologies. This ambivalent spell stirs up the fears and lights up the hopes of our societies in crisis. Its specific content is debated and its precise effects are largely unknown, but almost no one questions its historical significance and the qualitative change it introduces in the way we produce, manage, consume, live and die.” (1)

Evidence based medicine

What is “Evidence Based Medicine” if not “Medicine Based on Observation” after the impact of this Revolution on our work methodology? The observations, now more commonly called “data”, are produced by the millions and at an unexpectedly fast pace. The analysis of this data generates information and knowledge at a fraction of the time that it takes us to incorporate them into our medical practice.
To deny that this offers us endless opportunities, whether diagnostic, therapeutic, preventive, rehabilitative, etc., is to deny the Evidence. But we cannot overlook the shadows.
It is certainly impossible for us to determine the accuracy of the data; how and who turns them into information; how they decide to present this information; and how complete or partial the information is.

Mulgan warned us about this when he observed, “networks are created not just to communicate, but also to gain position, to outcommunicate.” (2)

In my opinion, part of the undeniable mistrust among a number of professionals with regards to the adoption of Medical Protocols and Guidelines stems from not knowing who is behind the information and what their vested interests are. Some events have contributed to this significantly.

Another shadow I want to point out is that contemporary science is characterized by on-line network communication that is global, but asymmetric at the same time.

I will try to clarify this apparent contradiction: The raw material of this technological revolution, we said, is information and consequently, if we do not contribute our “observations-data” to the global information, we will be ignored and no one will learn about our problems.

In this respect, the true consequence is that the problems of our patients, our citizens, will not be a part of the global world and we will be left on our own to solve them.

So we are seeing today that the majority of scientific discoveries that result from research reaches us through planetary networks, displays a fundamental difference between the types of problems being addressed. The problems of developing countries are not visible and, therefore, are of no concern to researchers and potential funders in developed countries.

The reality and the examples are sufficiently well known to need pointing out here: vaccines, malaria, Ebola, etc.

If this is so, and it is, what should we do about it in the healthcare industry?

We have the obligation to provide professionals access to reliable, scientifically validated information that is related to the social-health context in which they operate.We should provide professionals with the tools for organizing their observations-data, help convert them into information and this way become scientifically competitive. This, in turn, facilitates their access to global networks for scientific dissemination.

In my view, this is not just a medical necessity, it is an ethical and social necessity if one truly understands that access to scientific progress is the only way to contribute to a fairer global world.

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(1) Manuel Castell, et all. Nuevas Tecnologías: Economía y sociedad en España. Madrid: Alianza editorial, 1985.  ISBN 9788420690339

(2) Mulgan, G.J.  Communication and Control: Networks and the New Economies of Communicatio, Guilford Press, 1991. ISBN 9780898623116