The need for evidence in an anecdotal world.

One of the most difficult aspects of providing health care is the tension that exists between objective evidence, collectively accumulated over generations, and the fact that subjective practitioners deliver care one patient at a time. Although we may strive to understand the continuously developing scientific literature that is the foundation of our understanding of disease, it still remains far from obvious how exactly that literature should be applied to a patient who needs help. In science, the ostensible goal is the generation of data and knowledge that can then be applied as necessary. However, the delivery of health care is not a pure scientific process. There are many cases in which a patient’s satisfaction with his or her treatment will take precedence over the provider’s view of how well the treatment adhered to the best available evidence. And in the end, all of the evidence in the world may provide little comfort to a patient who has a poor outcome. There is a wide range of variables beyond a provider’s control that ultimately may have as huge an impact on a patient’s outcome as any randomized controlled trial. Rational decision making is easily disturbed when it comes to factors such as money, time, and emotion. Even when randomized controlled trials exist, it is often unclear how the results should be applied to patients whose profiles do not quite match those of the patients who were enrolled in the trials. As a result of these difficulties, there has been an ever-increasing emphasis on applicability—hence, the trend toward more translational research and the rise of clinician-scientists who naturally approach basic science from a clinical perspective. Meta-analysis has evolved as a useful approach to gather, evaluate, and consolidate the broad range of data available on just about any topic. The proper design and execution of randomized controlled clinical trials are widely accepted as the gold standards to be used when evaluating the quality of scientific data. These important developments, however, also shed an uncomfortable light on just how poor most of the clinical data have been to date (and continues to be today). This is not simply attributable to ignorance or lack of effort but instead to the realities of patient care where most questions to be answered just do not have randomized controlled trial data on which to base the answer. In the treatment of carcinomas of the ear, for example, this type of rigorous evidence is hard to come by. When a patient presents with this disease, surgeons do the best they can to interpret the available literature. However, the stakes are too high to proceed slowly, waiting for better data to become available as a tumor grows. As a result, we proceed swiftly, aware that our decisions are not based on the best possible evidence but rather that there are few alternatives—a decision must be made. Although not every patient has a life-threatening condition, this situation has obvious parallels to more routine situations—which hearing aid is really the best for a patient? What is the quality of the evidence to support one’s decision? It is almost impossible to ignore one’s own experience. In other words, the personal experiences we have as providers—anecdotal evidence if it were to be evaluated—typically do affect how we make decisions. Some of the wisest, most experienced practitioners in the world today are valued precisely because of the wealth of anecdotal evidence that they possess, and for a patient, it is more comforting to have an experienced, confident health care provider who has “seen it all,” than to have a naive student who may know the scientific literature extremely well yet has little personal experience. Most of the details that separate an experienced clinician from an inexperienced clinician will never be substantiated by high-level evidence and will instead remain anecdotal. Thus, it is important to acknowledge that we live anecdotal lives, personally, professionally, and even scientifically. The mistake, however, is to overestimate the significance of one’s own anecdotal evidence. What if two experienced practitioners have had completely valid yet exactly opposite experiences? It would be difficult to know how to decide the best course of action if we only had the benefit of these two opinions, as valuable as they may be. Instead, we would want to look beyond the experience of these two individuals. We would want to benefit from the accumulated wisdom and experiences of all of the practitioners that have encountered similar situations. We would want an unbiased, objective understanding of what the outcomes were. We would want to have all of the best available evidence, and we would want to differentiate this type of evidence from anecdotes that may be fascinating but perhaps irrelevant. We would also want to recognize that this evidence, however high in quality, is intrinsically limited and will itself become supplanted by newer, better evidence in the future. With this background in mind, I applaud the authors of the series of four articles presented here in this double issue. This series of articles begins with the idea that although evidence-based practice can be fraught with difficulties, it remains important to integrate high-quality research evidence and clinical experience to improve the quality and effectiveness of treatment for the patients in our care. The second article uses a knowledge-to-action framework to complete a synthesis of current audiological outcome measures for infants and children to be considered for inclusion in a guideline for clinical practice. The third article uses a pediatric audiologist community of practice to evaluate the individual components of the guideline called The University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP). The fourth article presents clinical data from infants and children with hearing loss who wear hearing aids to supply further evidence, including case studies, to augment clinical implementation of the UWO PedAMP in practice. It is notable how the articles presented here, though based on research done in Canada, apply equally well to those of us in other parts of the world. To me, these articles are a clear reminder that the hearing health sciences have often lagged behind in this effort to employ evidence-based practice. Articles like the ones presented here will hopefully contribute in a significant way toward the cultural shift—yes, our own lives are anecdotal and this is often how we learn. When it comes to proper treatment decisions for the delivery of health care, however, we should find something better than that.