More Evidence that the Hallowed RCT is Just a Demigod

I know I’ve written about this issue before – and I guarantee I will write about it again – but I assure you it is important enough to be discussed until even after it has been resolved. The Randomized Controlled Trial (RCT) has become something greater than life. It is the foundation of all Guidelines; it is the subject of Board test questions; it is the trump card in all roundmanship controversies. RCTs have taken on a power beyond all other aspects of medical knowledge. And I am sure this fact represents one of Medicine’s most perilous errors. Instilling RCTs with veto power across all lines of medical debate has relegated such things as clinical acumen, understanding of pathophysiology, and good old-fashioned common sense to second-rate skills. Endowing the RCT with omnipotence has all but eliminated the need for doctors and other health care practitioners to read extensively and understand the fundamental principals of medicine. Two recent examples plainly illuminate this problem.

In one case, a woman with a history of breast cancer as well as ASCVD finished her fifth year of Arimidex. Should she continue was the question, even though the medication might have been making it more difficult to effectively manage her lipids. No study had resolved this issue and so she decided to discontinue the medication. Troubled by her decision I contacted her oncologist and asked him what his gut suggested we do. He favored continuation of the medication. We listened to his well-honed instinct and simply fought a bit harder to control her cholesterol. Last week she was one of the first to have a test to predict the value of Arimidex continuation beyond year five. It turns out that she has a very high risk of breast cancer recurrence in the absence of drug. In other words, the oncologist’s gut was spot on. Perhaps the decision saved her life.

In another case, a friend recently told me that since our conversation regarding his atrial fibrillation four years ago – when I had suggested he stop drinking seltzer and also increase his magnesium intake – he completely stopped experiencing episodes of Afib. At the time he was having such frequent bouts of arrhythmias that radiofrequency ablation was strongly advised by all his physicians. Fortunately he tried an unproved treatment (which I, an electrophysiologist, had seen work in other patients) and it was entirely effective.  By trying something safe yet unproved, he was spared a potentially life-threatening procedure.

Reflecting on how we all practice medicine, I cannot but acknowledge the fact that most of our decisions are based upon data distinct from what can be found in the RCT. The bottom line: let’s respect and honor that which makes doctors more than just a commodity – our knowledge, instinct, clinical acumen, common sense, and sometimes our depth of caring.

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