Why are physicians so skeptical about positive randomized controlled clinical trials in critical care medicine?

Excerpt

Scientific evidence is an essential part of good medical practice. However, expert opinion, derived from personal experience and understanding of mechanisms, rather than scientific evidence is commonly used as a foundation for many decisions in medicine [2]. Practicing evidence-based critical care medicine is a difficult task; it must take into consideration the effectiveness of specific treatments in the context of patients who have multiple problems, and who are often receiving many different therapies in a setting that is different from those tested in most clinical trials. Although much of our care is based on expert opinion, results from many randomized clinical trials (RCT) have changed the practice of most critical care physicians. RCTs, when designed and performed appropriately, should provide the most reliable evidence of treatment effectiveness, particularly when the effects are small or moderate. Without clinical trials critical care physicians could continue applying ineffective and even harmful therapeutic interventions [3]. Recent RCTs enrolling large numbers of patients in the field of critical care medicine [4, 5, 6, 7] have reported harmful outcomes for well known treatments and beneficial effects of novel therapies. However, many clinicians do not translate the results of RCTs into clinical practice [8]. Several obstacles experienced by physicians can create barriers to the acceptance of RCTs [9]: lack of access to relevant information, lack of resources at the institutional level, lack of specialized training, incorrect interpretation or application of the evidence, rejection of evidence, influence of the clinical behavior at their institution, low salary, lack of financial incentives, reluctance to develop practice guidelines, and concern over increasing cost. …