Has 'Evidence-based Medicine' become a Joke?

In the late 1990s, evidence-based medicine was deemed innovative and the “be-all-do-all” for delivering care to injured workers. The EBM mantra advanced in the 21st century packaged in ever-evolving, proprietary treatment guidelines marketed as the key to reducing costs and improving outcomes.

But what has EBM become? For many workers’ compensation and disability management programs, EBM has devolved into automatic approval of physical therapy on every case, and diagnostic testing and treatment up to the maximum threshold provided in a particular guideline. And because the “approved” clinics or contracted network providers represent that they practice EBM, there are no questions asked about non-EBM practice patterns.  A few examples include unnecessary x-rays, add-on ice packs and pain creams, inappropriate use of advanced imaging for back pain, misapplied work restrictions, or the inattention to non-physical factors manifesting as a musculoskeletal injury.  

Wait!  What happened to pursuit of a timely and accurate diagnosis?  There is no financial incentive for such nonsense.    

If the diagnosis is not accurate, how can you apply EBM to the treatment?  And if the diagnosis is not plausibly derived from the workers’ job, do we simply continue the testing and treatment, hoping no one asks the questions, “Is this a work injury?” or with every clinic visit, “Why is the diagnosis – and often, the body region – changing?”   

Workers’ compensation is fee-for-service medicine that, too often, prioritizes payment for diagnostic tests and medical treatment over reasoning and accuracy.  We should not reward inefficiency and excessive diagnostic workups, office visits, consultations, and unnecessary surgeries.  Should there be refunds for ordering the wrong service or executing it poorly?  Or will the additional charges continue to be paid, with the economic costs associated with less-than-optimal outcomes borne solely by injured workers and employers.   

Maybe EBM is not a joke.  Instead, the joke is in the application of EBM.    

EBM must be aligned with proper economic incentives to reward timely diagnostic accuracy… and to hold those involved in the treatment of injured workers accountable for actually incorporating EBM into their clinical decision-making.