Con: Should Evidence-Based Medicine Be Used More in Clinical Practice?

A junior resident begins treatment of an elderly woman in the Emergency Department, who complains of severe epigastric abdominal pain for the last 6 hours with associated fever and vomiting. She has a rigid abdomen with diminished bowel tones, guarding and rebound. She is requesting pain medicine, but the resident refuses to give her any medications perhaps recalling the dogmatic teaching of his surgical attending, who claimed it would “mask” the etiology of her pain. When I came to see my mother-in-law 6 hours later, she remained in severe pain in spite of having a clear diagnosis of gallstone pancreatitis, based on physical, laboratory and ultrasonographic findings, and still had not received any pain medication. This in spite of a pantheon of articles finding that pain medication either improves or doesn’t change the sensitivity of physical exam findings in patients with abdominal pain. Clearly, evidence-based medicine needs to be used more in clinical practice, but there are limits within the Emergency Department.