By Robert G. Rassp, Esq.
The current trend across the country is to require evidence-based medicine for treatment of employees who are injured on the job. Statutory and regulatory mandates are emerging on a state-by-state basis. Stakeholders within the workers’ compensation community are not that familiar with the term “evidence-based medicine” or “EBM” and how it applies in establishing medical treatment for injured workers.
This article provides an explanation from a medical-legal standpoint as to what EBM is and its possible limitations in requiring it in work related injury claims in some jurisdictions. The use of the term “evidence-based” has medical as well as legal ramifications. The point of view expressed here merges medical treatment, medical research, and legal considerations for mandating EBM in clinical practice for the treatment of injured workers. California law will be used to demonstrate the mandate for use of EBM in its workers’ compensation system.
California Labor Code section 4600 mandates that the employer provide medical treatment for injured employees that “are reasonable and necessary to cure or relieve the effects of the injury.” The treatment must either cure or relieve the effects of the industrial injury, and the plain language of the statute has been interpreted to mean that the term “cure” and “relieve” refer to either curing or relieving the effects of an industrial injury, even if the treatment is “palliative.” See Bige v. I.A.C. (1930) 105 Cal. App. 210, 287 P. 577.
WHAT IS EVIDENCE-BASED MEDICINE?
As of 2004, California Labor Code section 5307.27 mandates that the Administrative Director of the Division of Workers’ Compensation adopt a medical treatment utilization schedule (MTUS) “that shall incorporate the evidence-based, peer reviewed, nationally recognized standards of care…that shall address, at a minimum, the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers’ compensation cases.” In addition, California Labor Code Section 4604.5 mandates evidence-based medicine be used in its workers’ compensation system and all treatment guidelines are presumptively correct and can only be rebutted by a “preponderance of scientific medical evidence establishing that a variance from the guidelines reasonably is required to cure or relieve the injured worker from the effects of his or her injury.”
This statutory mandate was in response to skyrocketing medical treatment costs that were mainly caused by a minority of medical providers and legal representatives of injured workers. Introducing EBM into the workers’ compensation system was a political decision as much as it was an economic one. It was not unusual, for example, for a chiropractor to run up bills for spinal adjustments, other physical therapy modalities, and “managing” the care of injured workers to the tune of over $100,000.00 – in soft-tissue cases. So the introduction of EBM into the workers’ compensation system was a reaction by the payer community to a very small minority number of stakeholders in the system. This was like using a sledgehammer on a stuck glass window.
The statutory mandate to adopt “treatment procedures and modalities commonly performed in workers’ compensation cases” implies that doing so is to the exclusion of utilizing community standards of medical care or “personalized medicine” that someone would be entitled to outside of the workers’ compensation arena. This distinction will become clear when comparisons are made between what care patients get for the same diagnosis for the same part of body injured as a result of non-work related injuries from those that are work related.
The actual definition of “evidence-based medicine” depends on what context it is used in. For the purpose of treatment in a workers’ compensation case, mandating the use of EBM results in the exclusion of community standards of care as will be explained below. By its definition alone, it is misleading to even use the term “evidence-based” in this context because of the limitations of the evidence itself.
“Evidence-based” is defined in California regulations as “based, on a minimum, on a systematic review of the literature published in medical journals included in MEDLINE.” See Title 8 California Code of Regulations section 9792.20(e). MEDLINE is the shorthand reference to PUBMED, which is the National Public Library of Medicine (www.nih.gov/pubmed). The literature published in PUBMED consists of scientific articles, studies, and publications such as the Journal of the American Medical Association (JAMA), the New England Journal of Medicine (NEJM), Annals of Internal Medicine, Cochrane Review, etc. The articles that are accessible in PUBMED have all been peer-reviewed and involve nationally accepted standards of research. See e.g. 45 CFR § 46 et seq.
EBM is more formally defined in the ACOEM (American College of Occupational and Environmental Medicine) Practice Guidelines, 2nd Edition (2004) relating to the strength of studies that support the effectiveness of a given treatment protocol. See Title 8 California Code of Regulations sections 9792.20(a) and (b). The California medical treatment utilization schedule adopts the scientific weighting system that is advanced by the adherents to EBM and that is also utilized to a certain extent in medical research.
Title 8 of the California Code of Regulations, section 9792.25 is entitled “Presumption of Correctness, Burden of Proof and Strength of Evidence” in setting the stage for EBM in the treatment of injured workers in the California workers’ compensation system. The regulation creates a rebuttable presumption that the MTUS is correct “on the issue of extent and scope of medical treatment and diagnostic services addressed in the MTUS for the duration of the medical condition.” The section goes on to require the burden of proof to rebut the MTUS by presentation of “scientific evidence establishing that a variance from the schedule is reasonably required to cure or relieve the injured worker from the effects of his or her injury.”
Section 9792.25 establishes the order of treatment determination from the strongest to the weakest:
> If a treatment protocol is in the MTUS, that protocol applies in every case. See Title 8 Cal. Code Regulations section 9792.25(a).
> If the treatment protocol is not in the MTUS, then the authorized treatment shall be in accordance with other scientifically and evidence-based medical treatment guidelines that are nationally recognized by the medical community. See Title 8 Cal. Code Regulations section 9792.25(b).
> Finally, if treatment for the medical condition is not addressed by the MTUS and is not in other evidence-based treatment guidelines (such as the Official Disability Guidelines (ODG)) or if there are conflicting treatment guidelines, then a “strength of evidence rating methodology” system is adopted that has to be scientifically based and published in peer reviewed national journals. The rating system is based on the strength of the scientific study or studies which justifies the treatment. The strongest scientifically based study is a double blind, placebo controlled, randomized study where the participants in the study are seeking treatment for the same medical condition and all participants are in the same group (all males, all females, equal number of both, etc). These are referred to in the ODG and other guidelines as “RCT”, meaning “randomized clinical trials.”
The strength of evidence methodology is only used if the MTUS and other medical treatment guidelines do not cover the medical condition. The grading system is the same as the one used in the ACOEM Practice Guidelines, with a “grade” of:
> A Strong evidence base: One or more well-conducted systematic reviews or meta-analysis (a study that reviews data from prior studies), or two or more high quality studies.
> B Moderate evidence-base: At least one high quality study, a well conducted systematic review or meta-analysis of lower quality studies relevant to the topic and the working population.
> C Limited evidence-base: At least one study of intermediate quality.
> I Insufficient Evidence: Evidence is insufficient or irreconcilable.
So medical treatment for injured workers in California are based on the MTUS, which itself is based on evidence-based medicine, nationally accepted peer reviewed treatment guidelines, or a review of specific studies for medical conditions that are not in the MTUS or other guidelines. The MTUS itself is a consensus-based rubric that is also evidence-based, primarily derived from the field of occupational medicine, focusing on industrial injuries.
In all fairness to EBM, the standards of EBM are not static – they have to be updated periodically since science is always evolving and medical treatment protocols have changed. For example, twenty years ago bariatric surgery for weight reduction was rarely, if ever, reimbursed in group health plans. Eventually, studies showed that bariatric surgery for patients with a BMI of greater than 30 resulted in both cost effectiveness and in cost savings for health insurance payers.
COST EFFECTIVENESS AND COST SAVINGS
Cost effectiveness means that if an insurance company pays up front for a medical procedure, that expense is ultimately lower than what it would have cost for treating the patient by alternative treatment protocols to achieve the same result. So it is more cost effective to pay $30,000.00 for bariatric surgery than it would cost for treating the same patient over time with non-surgical treatment for obesity – the overall cost of treatment for obesity is less with surgery than without to achieve the same outcome, i.e., significant weight loss. Cost savings means that bariatric surgical treatment is cheaper than the long term medical expenses to treat the consequences of obesity, such as diabetes, heart disease, and orthopedic conditions.
EBM DISTINGUISHED FROM MEDICAL RESEARCH
How is EBM distinguished from medical treatment research protocols? In medical research, studies are conducted with strict limitations on the selection criteria of participants and the medical diagnosis, and on involving a very limited scope of research in which the researcher and participants do not know who gets the study drug or who gets a placebo. Clinical medical research studies are highly regulated, and the results of those studies sometimes form the basis for clinical practice and treatment protocols. However, most clinical medical research involves the development of safe and effective new investigational medications, devices, biologics, or procedures. See 45 CFR § 46 and the Food and Drug Act, Title 21 U.S.C. and 21 CFR § 56 et seq.
EBM vs. PERSONALIZED MEDICINE
How does EBM differ from clinical medicine or “personalized medicine?” In any clinical medical practice, from an ethical standpoint, the patient comes first. In other words, physicians treat illness, injuries and disease with one thing in mind – cure or relieve the effects of that illness, injury, or disease using the community standards of care that are personalized to each patient. So if a given treatment is effective for only five out of a hundred patients, ethically, a physician has a duty to try that treatment on all patients who present with the same diagnosis.
However, there is utilization review embedded in most health insurance plans but those protocols are not as stringent as those that we see stemming from EBM in workers’ compensation claims. In fact, when there is a utilization review (UR) denial in group or individual health insurance, a peer-to-peer discussion between the requesting physician and the UR doctor is standard practice, and most UR disputes are resolved without Independent Medical Review intervention. Also, the UR doctor is usually a true peer of the requesting physician - a California licensed board certified specialist who has the same credentials and scope of practice as the requesting physician, which is not required in utilization reviews for treatment of injured workers in the workers’ compensation system.
For example, a 56-year-old man is diagnosed with prostate cancer and has his prostate surgically removed. His PSA (prostate specific antigen, see www.cancer.gov/cancertopics) test should be 0.0. Four years after surgery his PSA starts to rise rapidly, and his urologist requests authorization for forty directed radiation therapies. The patient’s health plan denies authorization for the radiation because “his PSA is not high enough.” The treating urologist and the patient file an internal appeal of the utilization review denial, and the treating urologist discussed the case with the utilization review physician and told him that the rapid increase in PSA shows that the cancer has returned and will metastasize if the radiation therapy does not get authorized. The peer-to-peer discussion solved the matter, and the radiation therapy was authorized in 30 days from the date the request for authorization was received by the health care payer.
THE PROBLEMS WITH EBM
In reality, very few treatment protocols are based on “strong evidence-based” medicine for the simple reason that excluding patients from medical treatment that seems to be effective is unethical. In fact, participants in medical research are told as part of the informed consent process that they are not to expect any benefit from their research participation and the participation is for research and not for treatment of their medical condition.
FDA approval of medications, biologics, and devices for general use undergo three phases. Phase I studies occur after animal studies and involve a very small group of study participants. Phase I is strictly required to determine safety of the medication, biologic, or device. Phase II determines the safety and efficacy of the medication, biologic, or device. Phase III determines the dosage ranges, safety, efficacy, and known side effects. Once the FDA approves the drug, biologic, or device, it approves the use of the product, and a Phase IV study is a post-marketing, post-approval determination of effectiveness, safety, and side effects for the general use of the product. See, generally 21 U.S.C. § 1 et seq. and 21 CFR § 56.
The problem with these studies and the studies involving the development of EBM standards in the MTUS, ODG, and other “guidelines” is the number of participants in the studies, the inclusion and exclusion criteria for those participants, who the sponsor of a study is, and whether or not there is a placebo.
The number of participants in a study may be limited for many reasons, including the fact that medical research is expensive. Sometimes a small number of participants in medical research do not include people with the same medical condition but who also have co-morbidities (other disease processes) at the same time. Their participation in the research is too risky, and they are excluded from the study. Sometimes the sponsor of a study is important because many sponsors sink millions of dollars into a study medication, device, biologic, or procedure and the sample of study participants is skewed towards individuals who would most likely show benefit from the study drug, device, biologic, or procedure. This is called “study bias” and can be a significant problem with the integrity of medical research. Sometimes a study cannot include a placebo because the use of a placebo may be unethical.
For example, in cancer studies, use of a placebo is prohibited since the standard of care is required as part of cancer studies and investigational methods are adjuvant to the standard of care. Finally, sometimes there is a “placebo effect” in which patients report feeling better simply because they are participating in a medical research study that has nothing to do with the efficacy of an experimental drug, device, biologic, or procedure.
Most importantly, the MTUS, ODG guidelines, and other studies on which EBM is based rely on studies that do not include all possible sub-groups of patients who have the same diagnosis. Most of the published studies on which EBM is based excluded pregnant women, diabetics, and the obese from participation in the studies of treatment protocols. Put simply, one size of treatment does not necessarily fit all. Treatment mandated under EBM is not necessarily effective for everyone with the same medical condition.
A great example of this is the FDA approval of the implantable defibrillator for patients who had a heart attack and are at risk for sudden cardiac death. During the FDA approval process, patients who had three of the following conditions were excluded from the studies: patients with diabetes, hypertension, heart failure, atrial fibrillation, and renal dysfunction. So the sub-group of patients who were excluded from the study is at a disadvantage with absolutely no data on the risks, benefits, or complications from the use of this device. Physicians would not know if the device would work for these excluded patients – would the device increase life expectancy or would the risks of infection, no survival benefit, or inappropriate shocks make implantation contraindicated? See Goldberger, Jeffrey and Buxton Alfred “Personalized Medicine vs. Guideline-Based Medicine,” Journal of the American Medical Association, 2013 Vol. 309, no. 24.
In their article, Goldberg et al. said: “The conflict between guideline based medicine and personalized medicine predominantly occurs when considering withholding a therapy that is recommended or supported by the guidelines but that may not be beneficial for an individual patient.” This articulates the problem with EBM. The studies that support EBM protocols such as the MTUS and other guidelines that are peer reviewed and nationally recognized also excluded many patients for those studies, and the treatment protocols that are EBM do not work with sub-groups of patients with the same medical diagnosis.
A similar problem with EBM and guidelines occurs when a treatment modality works in only 5 out of 100 patients. Such a treatment modality would probably not make it into a treatment guideline because in 95% of the patients it would not be efficacious and would be a waste of money. In personalized treatment, if a clinical physician who is not subject to EBM feels in his or her clinical judgment that a given patient might benefit from that modality and the risk of harm is minimized, then he or she may recommend it.
From an ethical standpoint, a treating physician should have treatment modalities that work in some patients in his or her arsenal even if some modalities do not work in the majority of patients. This is called “equipoise”, which means if something works in some patients but not in others, if the risk/benefit ratio is reasonable for a given patient, you give equal access to that modality, given the fact that some patients will benefit from it and you cannot predict who will and who won’t benefit. That is the essence of individualized medical care. If a medical procedure that is not within an EBM framework works in one half of one percent of patients, that’s a lot of patients in a state of 35 million residents! Where do you draw the line - 1%, 5%, 10% of patients?
RADIO FREQUENCY RHIZOTOMY
A radiofrequency rhizotomy is an option for patients who suffer from facet joint disease. The procedure requires an incision under light anesthesia and the physician ablates the nerve root at the levels of the spine that are suspected that cause the symptoms. The relief from back and leg pain from this procedure lasts between 18 and 24 months because the nerve root grows back. While rhizotomies are commonly allowed in general health plans, they are frequently denied in workers’ compensation cases as not reasonably necessary. The controversy exists from two sources – the first is that there are conflicting studies for the efficacy for rhizotomies in the literature, and secondly there is a disconnection between the terms “cure” and “relieve” that are mandated in Labor Code Section 4600. See U.S. Fidelity & Guaranty Co. vs. Dept. of Industrial Relations (Hardy) (1929) 207 Cal. 144, 150, 277 P. 492, 16 IAC 69.
The MTUS and other EBM guidelines emphasize the concept that medical treatment for a work injury must result in functional improvement. Medical procedures such as physical therapy and rhizotomies only provide palliative benefit and probably no long term functional improvement occurs in the absence of other treatment modalities. This is why many utilization reviewers do not certify long term physical therapy modalities or rhizotomies where benefits are only temporary. EBM standards do not account for providing treatment to “relieve” the effects of an injury, and this is the problem with the use of EBM for medical treatment in California workers’ compensation claims. If a treatment modality only provides palliative benefit, then most if not all EBM treatment guidelines do not allow that modality because there is no evidence of functional restoration from these types of treatment.
Rhizotomies are not listed in the California MTUS or in the chronic pain guidelines. The procedure is described instead as “Facet Joint Radiofrequency Neurotomy” on pages 865 through 866 of the ODG Guidelines (ODG Treatment In Workers’ Comp 2013, 11th Edition, Work Loss Data Institute) under Procedure Summary – Low Back. Traditionally, rhizotomies are used by neurologists for treatment for certain seizure disorders and for trigeminal neuralgia. See ODG, pages 433 and 442. As of the current edition of the ODG Guidelines, rhizotomies for lumbar facet joint disease is “under study” and “Conflicting evidence is available as to the efficacy of this procedure and approval of treatment should be made on a case by case basis (only 3 RCTs with one suggesting pain benefit without functional gains, potential benefit if used to reduce narcotics). Studies have not demonstrated functional improvement.” The authors of ODG then indicate that all of the studies had flawed methodologies but systematic reviews of prior studies show some improvement for leg and hip pain.
The California MTUS also has post-surgical guidelines including those for post surgical lumbar spinal procedures. Up to 20 post surgical physical therapy sessions can be authorized if there is evidence of functional restoration such as improved range of motion and pain reduction. Title 8, California Code of Regulations section 9792.24.3 states:
As compared with no therapy, therapy (up to 20 sessions over 12 weeks) following disc herniation surgery was effective. Because of the limited benefits of therapy relative to massage, it is open to question whether this treatment acts primarily physiologically, but psychological factors may contribute substantially to the benefits observed. (Erdogmus, 2007)
Artificial Disc [DWC]: Postsurgical treatment: 18 visits over 4 months*Postsurgical physical medicine treatment period: 6 months
Fracture of vertebral column with spinal cord injury (ICD9 806): Postsurgical treatment: 48 visits over 18 weeks*Postsurgical physical medicine treatment period: 6 months
Fracture of vertebral column without spinal cord injury (ICD9 805): Postsurgical treatment: 34 visits over 16 weeks*Postsurgical physical medicine treatment period: 6 months
Intervertebral disc disorder with myelopathy (ICD9 722.7): Postsurgical treatment: 48 visits over 18 weeks*Postsurgical physical medicine treatment period: 6 months
Intervertebral disc disorders without myelopathy (ICD9 722.1; 722.2; 722.5; 722.6; 722.8): Postsurgical treatment (discectomy/laminectomy): 16 visits over 8 weeks*Postsurgical physical medicine treatment period: 6 monthsPostsurgical treatment (arthroplasty): 26 visits over 16 weeks*Postsurgical physical medicine treatment period: 6 monthsPostsurgical treatment (fusion): 34 visits over 16 weeks*Postsurgical physical medicine treatment period: 6 months
Spinal stenosis (ICD9 724.0): See 722.1 for postsurgical visits*Postsurgical physical medicine treatment period: 6 months
These guidelines are for post surgical visits to the treating physician. The first entry above refers to 20 physical therapy visits post surgery. In reality, most patients who have lumbar spinal surgery of any kind do not fully recover from the surgery for six months to one year. In addition, Section 9792.24.3 also indicates that if physical therapy does not improve function, further therapy should be discontinued. In medical practice outside the workers’ compensation arena, many patients do not have or need post surgical physical therapy at all, or some rely on post surgical therapy for years after having back surgery. This is the difficulty of imposing medical treatment restrictions for a serious life altering condition resulting in surgery. Anyone who has had low back surgery of any kind will tell you that there has to be lifestyle changes and alterations in activities of daily living, recreational pursuits and work methods on a permanent basis.
EPIDURAL STEROID INJECTIONS
Treatment with ESI for lumbar spinal conditions is controversial in the workers’ compensation arena but is standard treatment in group and individual health insurance plans. In fact, some patients who have significant lumbar spinal pathology benefit for years from an annual series of epidural injections as an alternative to more invasive spinal surgery. In the California workers’ compensation system, ESI is subject to utilization review denials on the basis that the MTUS and other guidelines severely limit use of ESI. See, ODG Guidelines 11th Edition, pages 826, 854-857. The evidence that is cited by utilization reviewers, independent medical reviewers, and medical examiners involve different sections of the MTUS and other guidelines to either authorize ESI or to deny them. Why the inconsistent decision making?
A recent article in the Journal of the American Medical Association (Staal, J. Bart, Nelemans, Patty, de Bie, Rob “Spinal Injection Therapy for Low Back Pain” June 19, 2013 Vol. 309, No. 23) reflects the reasons for the conflicting opinions. The article is a meta-analysis of prior studies of ESI safety and effectiveness.
All of the studies of the effectiveness of ESI treatment for lumbar spinal conditions involved a heterogeneous group of patients. None of the patients within each study had the same level of pathology, such as L5-S1, the same symptoms, or the same substance injected. There were very few studies with placebo injection versus active injection since the ethical considerations for the most part prohibited this type of study.
Illustrating the problem with using the MTUS, national treatment guidelines, and evidence-based medicine, you must become familiar with the variables that a physician faces in treating a patient with low back pain using ESI therapy. The authors in the AMA article point out those variables: the target location for the injections, the type of pharmaceutical agent being injected (anesthetics, steroid, non-steroid anti-inflammatory, etc.); dosages of the pharmaceutical agent; the underlying source of the pain – facet joints, epidural space, intervertebral disks, ligaments, muscles, or trigger points; and the stage of low back pain – acute, sub-acute, or chronic.
All of these variables were not consistent within each reviewed study. Most studies reviewed actually recommended a combination of oral opioid and NSAID medications, exercise, and behavioral therapy over epidural steroid injections from a clinical practice standpoint! See Dagenais, S, Tricco, AC, Haldeman, S. “Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines.” Spine Journal 2010, 10(6): 514-529.
The authors in the JAMA article conclude: “Patients with low back pain differ in their clinical presentation and may respond differently to treatments. Injection therapy of any kind may be beneficial in individual cases or sub-groups.” See JAMA, id. at 2440. Then they come to the inexplicable conclusion that ESI therapy should not be used for low back pain! The problem is that the authors do not identify any “sub-groups” because they were excluded from the reviewed studies. Why?
For example, most clinical studies involving the use of steroids show that people who are diabetic or who are borderline diabetic (fasting blood sugar is between 100-125 mg/Dl) have an aggravation of the diabetes that is caused by steroid therapy. So diabetics were mostly excluded from the studies that tested the effectiveness of ESI on that sub-group of patients.
The above example of ESI demonstrates the overall problem with the MTUS, treatment guidelines, and research studies – that these guidelines do not account for every patient who is subjected to those protocols. The inherent conflict between the use of these guidelines and individualized medical treatment results in creating friction between the treating physician and the payer of his or her services who insist either by contract, statute, or regulation, on using EBM. Simply stated, there is a conflict between individualizing treatment for a given patient versus following a legal requirement by statute or regulation or both to follow pre-designated treatment guidelines for every patient.
LABRAL TEAR IN HIP JOINT
Another example of the difference between treatment allowed in a workers’ compensation claim and treatment allowed under general group or individual health plans is for patients who have a labral tear in the hip joint. With respect to a work related hip injury, EBM and statutory limitations for up to 24 physical therapy visits in non-surgical cases restrict a physician’s options. See, for example, California Labor Code Section 4604.5(d). If surgery occurs, the procedure is less than desirable or effective – a patient’s leg has to be placed in traction, the hip joint “distracted” to produce a greater than 4mm access for the arthroscope and surgical instruments to repair the torn labrum. Sometimes the surgery does more harm than doing nothing.
In contrast, the same labral tear would allow up to 75 physical therapy visits under a group or individual health plan because the literature shows that extensive physical therapy is more effective in treating a labral tear of the hip than surgery. So what treatment applies? Cost saving restrictions of EBM or local community standards of care upon which health insurance is based? Remember, health insurance premiums vary by locality due to the accessibility for specialized treatment and equipment. There is a total disconnect when you compare treatment for the same condition through a work injury as opposed to private or group health plans. This is probably an intended consequence to impose EBM in work injuries.
EBM has been adopted in workers’ compensation cases as a cost saving measure and in response to over treatment by certain medical providers who were and are profiteering from the workers’ compensation system. However, the adoption of EBM, an MTUS, and treatment based on research studies conflict with a physician’s desire to provide the best treatment for a given patient, regardless of any existing guidelines. Comparing clinical practice to EBM is like comparing apples to oranges.
It should be noted in all fairness, however, that the rigid guidelines in the MTUS and other EBM treatment protocols do allow for variance provided that a physician can show efficacy of a non-scheduled modality. So what if you are an outlier patient? Does this mean EBM prevents you from receiving standard of care? What happens when a guideline required treatment does not work? What if an effective treatment that is not in a guideline is non-certified? Can EBM be hazardous to your health?
Our system of workers’ compensation medical treatment guidelines need to be flexible enough to account for these trends so that a person gets the same standard of care if his or her injuries are from a fall down a flight of stairs at home as opposed to a fall down a flight of stairs at work. Ethically, a physician should be allowed to provide an individualized treatment plan for work related injuries based on clinical practice guidelines that are the same for work and non-work related injuries that promote cost effectiveness and cost savings, if possible. But the number one priority for any patient – work related injury or not – is to provide the best and effective treatment based on local community standards of care with guidelines only acting as guidelines and not as a limitation for effective treatment.
The discipline of medicine is a combination of art and science. EBM potentially eliminates the “art” of medicine – the ability for a physician to exercise his or her clinical judgment in a given case and to provide each patient with the most appropriate and effective treatment plan.
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