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Sometimes an experienced-based hunch may prove more useful than evidence-based guidelines.
Evidence-based medicine has taken center stage. Adherence to "best evidence" is everything; individual judgment and long experience count for nothing. "Experience" is ridiculed as anecdotal. Most physicians try to keep up with the latest studies and guidelines, changing our practice patterns when the data warrants it. But veteran doctors also know that generalized guidelines don't always apply when diagnosing and treating individual patients.
Take the case of Rona, my former office manager. Since she'd moved away years ago, she had kept in touch becauseas she was fond of sayingwithout my help, her children would never have been born.
When Rona first applied for a job as a medical assistant, I almost rejected her immediately because she had no medical background, and was a heavy smoker. But she insisted she was a quick learner, and promised to quit smokingwhich she did.
Taking a chance on Rona was one of the best decisions I ever made. She soon became the best phlebotomist I ever had, and she had a wonderful way with patients. In our small office, our staff needed multiple skills, and Rona soon learned to handle our computerized billing system. Eventually she became my trusted office manager.
One day after the last patient had left, Rona told me about her long and unsuccessful struggle to become pregnant. Until then, I had wrongly assumed that she and her husband simply weren't interested in having children. She recounted years of exams, tests, and consultations with fertility specialists. Every test had turned up negative, and there was seemingly nothing to be done.
When Rona asked if I could help, I replied, "Maybe, but I don't want to promise anything, or raise false hopes."
"Don't worry," said Rona. "I've lost hope anyway, so there's no harm in trying."
The next day I examined Rona. Her routine gyn exam was normal, but her cervix looked a little red, with a mucoid yellow-white material on it, which, on wet smear, was rich in white blood cells. I then examined her husband, and again everything seemed normal. I sent him for a complete semen analysis, however. It came back showing white blood cells on microscopy, and a significant colony count on culture.
I had been successful before in treating couples who had been unable to conceive due to similar problems: a wife with unrecognized and untreated cervicitis and a husband probably with a low-grade unrecognized chronic prostatitis. How could sperm thrive in such an inhospitable milieu?
I had no solid proof to back up my theoryonly logic, case-based evidence, and an educated hunch, based on mechanisms of disease and years of experience. (Years later I did come across a few references in the medical literature to cases like mine.)
I explained my theory to Rona and her husband, and recommended treating their presumptive infections with broad-spectrum antibiotics. They agreed. I gave them both two full weeks of doxycycline and metronidazole. They returned for follow-up exams just as the treatment was ending. Rona's cervical discharge was gone; her husband's semen had no white cells, and cultured negative. I told them to resume relations every three days and to enjoy life. After two months, Rona was pregnant.
Now, years later, I still marvel at her two beautiful daughters. Was it Lady Luck, or Lady Logic? Was it evidence, or providenceor perhaps a little of both?
Pepi Granat. Last Word: Experience or evidence?. Medical Economics Apr. 25, 2003;80:112.