In our efforts to promote value, the need to reduce unnecessary variation and follow best practices in the form of clinical guidelines is clear. As we think about moving toward more evidence-based practice, it may be worth considering some of the alternatives:
1. Eminence-based practice. This is where we do what we are told by people who, rightly or wrongly, are well-known in their field. Although in many cases this may be reasonable and congruent with available evidence, assuming something is correct based solely on the celebrity of a source can be problematic. (See, for example, Tom Cruise and Scientology.)
2. Precedence-based practice. This falls under the category of “we’ve always done it that way.” It is particularly prevalent at certain ivy-clad East Coast institutions, and is the reason we continued to use theophylline for acute asthma well into my fellowship years. (The cutting edge doesn’t work when it is stuck in cement.)
3. Elegance-based practice. This is perpetuated by pharmaceutical and other manufacturers, who promote questionable products with eloquent testimonials and attractive advertising. The poster child for this is Xopenex.
4. Arrogance-based practice. When one is willing to substitute one’s own thin anecdotal experience for the accumulated wisdom of the published literature. Often expressed in the form of “my patients are different.”
5. “Are you dense?”-based practice. Also known as “execrance-based practice,” this is an extreme form of variant #4 above, whereby not only does one assume one’s own practice is superior to the published evidence, but that all other practices are idiotic.