Medicine in general and ophthalmology in particular are transiting from doctors making individualized decisions based on personal experience and expertise to decisions made based on “the study”. These studies are based on a highly scientific approach, the elements of which include randomization, large patient populations, multiple treating facilities and physicians, prospective planning, and objective analysis of the non-biased results. While such studies brought tremendous progress in identifying the best treatment option for the question asked, they have inherent problems as well. These include, among others, high cost, an arduous planning process, an erroneous conclusion if the study design was flawed, and a long time from study idea to study publication (during which time the original question asked in the study often becomes obsolete). There are two additional, rarely discussed problems inherit in the fact that such studies become sacrosanct (so that questioning the study’s conclusions makes the challenger appear a science-denier). One, journals are increasingly reluctant to accept and publish case reports or series that do not satisfy to the rigors of the Level-1 evidence-based study; two, physicians rely on such studies in their daily practice to the extent that they blindly follow them. The latter makes doctors act more like robots, where the patient who presents with a complaint is basically put on a conveyor belt that spits out an “objective” pathway, which leads to a diagnosis based on what was the abnormal finding identified by the tests, and then a mechanical execution of the recommendations by the latest Level-1 evidence-based study for that particular abnormality. What is missing from this type of practicing medicine is the individual patient. You do not need to have a medical doctor’s training and diploma to identify macular edema on an OCT scan (AI [artificial intelligence] will do that in the not too distant future) and then to give an intraocular injection for it. This talk will review a few examples to show where the “Level-1 evidence-based study” movement goes wrong, and argues in favor of making individualized management decisions based on the taking into consideration currently the missing piece in the puzzle in the era of the Level-1 evidence-based study dictatorship: the patient.



Ferenc KUHN
St. Johns
Email : fkuhn@mindspring.com
Cell Phone: +19044636428
Work Phone: +19044636428