James R. Kopp, M.D.
EVIDENCE BASED EXPERT OPINIONS
Evidence based medicine is grounded on the principle that physicians should utilize the information available in the literature to assist with treating patients and forming their expert opinions.
“Evidence-based medicine (EBM) is regarded as a new paradigm in medical practice, equal in enormity to the human genome project.”(1) “In contrast to the traditional paradigm of clinical practice, evidence-based medicine acknowledges that intuition, clinical experience and pathophysiologic rationale are not sufficient for making the best clinical decisions.”11 Evidence-based orthopedics is part of this broader movement of evidence-based medicine which is steadily gaining prominence.(2)
To quote Douglas McGee, DO: “Physicians have always felt that their decisions were based on evidence; thus, the current term “evidence-based medicine” is somewhat of a misnomer. However, for many clinicians, the “evidence” is often a vague combination of recollected strategies effective in previous patients, advice given by mentors and colleagues, and a general impression of “what is being done” based on random journal articles, abstracts, symposia, and advertisements.”(7) McGee goes on to say that, “EBM is built on reviews of relevant medical literature and follows a discrete series of steps.”(ibid)
EXPERT OPINION VS EVIDENCE BASED MEDICAL EXPERT OPINION—3 EXAMPLES:
1. Injury to one extremity will increase likelihood of injury to the other.
- A person sustains a right knee injury. During the course of the treatment and rehabilitation, the claimant will use his/her left knee more than before the injury. This may lead to increased symptoms in the left knee. Medical Expert Opinion will often indicate, as a matter of common sense, that the left knee symptoms are related to the right knee injury.
- In fact, evidence based outcomes indicate the reverse is true. When one uses an extremity more, the extremity strengthens. This is why sports injuries are so vigorously exercised in the recovery process.
- This concept of contralateral injury due to overuse is so often misunderstood, and so important, that the AMA’s Guides to the evaluation of Disease and Injury Causation, Second Edition devotes an entire chapter to it.(8)
2. Carpal tunnel syndrome is related to keyboarding.
- With the new computerization of data entry, many jobs have been created which consist primarily of keyboarding. Logically, physicians will associate the activity of keyboarding with the development of carpal tunnel syndrome—using the principle of Post Hoc Ergo Propter Hoc (after it, therefor because of it).(8)
- In fact, evidence based medicine shows that repetitive tasks alone have “conflicting evidence” and keyboarding specifically has “insufficient evidence.”(ibid)
3. Facet block Injections are helpful for low back pain.
- Low back pain is a leading cause of disability, and while acute low back pain is usually self-limiting, chronic low back pain is a much more difficult problem, and is often associated with strong psychologic overlay.(4) Multiple efforts at non-surgical treatment of chronic low back pain have been developed, more recently steroid injections into the facet joints of the back. These are still frequently recommended.
- Evidence-based studies have shown that facet joint injections produce no long term relief of chronic low back pain over that of any other treatment modalities. Medial branch blocks and radiofrequency neurotomies have only produced short-term relief.(13)
RELATIVE VALUE OF SCIENTIFIC EVIDENCE
Since all scientific evidence is not the same, recent attempts to rank the value of the scientific evidence have also added to the value of the evidence obtained. Grades of recommendations are graded A, B, C and I. A = good evidence, B = fair evidence, C = conflicting or poor quality and I = have insufficient evidence to make a recommendation.(16) For instance, a case report of a single instance of a medical treatment outcome (Grade B or C) does not have the same weight as a meta-analysis (Grade A) which may involve hundreds or thousands of outcomes over several treating institutions.
Another classification appears in the American Academy of Orthopaedic Surgeons’ Orthopaedic Knowledge Update 10. Level I evidence is best and is high-quality randomized trials. Level II is lesser quality random trials with less than 80% follow-up or improper randomization. Level III is based on case-control studies, or retrospective comparative studies. Level IV is a case series. The lowest level of evidence is level V for expert Opinion.(9) Similarly, Bains, et.al., suggest randomized, controlled trials are at the top of the evidence value curve, while case reports and expert opinion are at the bottom.(2)
Expert opinion being at the bottom of the evidence chain in importance is also recognized outside of orthopedics. Psychiatrist G.E. Gray indicates, “In the hierarchy of the types of clinical evidence, expert opinion is at the very bottom.”(5) Gutheil and Simon add that narcissism may play an adverse role in the value of expert opinion.(6)
The expert is still needed however, as explained by Dr. Simon: “Employing Evidence-based treatments does not automatically establish that the standard of care has been met.”(14)
Most attorneys and judges say an honest opinion is what is desired from an expert. To a lay person, who knows that the outcome is what determines the success of legal representation, there may be some doubt about the legitimacy of a legal representative who wants an honest, rather than a favorable opinion. To this, I would submit that an honest opinion, even though it may be averse to an attorney’s desired outcome, is still quite valuable because it allows the attorney to be prepared if that opinion is offered by others. I have come to realize that attorneys want an honest opinion for that very reason. This was expressed by multiple plaintiffs’ attorneys, prosecutors, judges and insurance representatives at an Expert Witness Conference meeting in Chicago,(12) as well as by Mr. Sakall in his presentation.(10)
Also, it is the task of the expert to teach the triers of fact, not to be the triers of fact.(12) As rather eloquently and succinctly stated by Dr. Jim Talmage, “Remember, Law TRUMPS Medicine. Your job is NOT to win.”(15) He goes on to say, ““Remember, Law TRUMPS Medicine. Your job is to TELL the TRUTH.”(ibid)
ABOUT THE AUTHOR
James R. Kopp is an orthopedic surgeon and experienced expert witness who utilizes evidence-based medicine in formulating his expert opinions. He is licensed in Oregon, Washington, Idaho, Arizona, and Alaska. He can be reached at firstname.lastname@example.org, (541) 786-9607, and www.koppmedical.com
- Akai, Masami: Evidence-based medicine for orthopedic practice. J. Ortho. Science, Vol. 7, No. 6, pp 731-742, 2002.
- Bains, Simrit; Bhandari, Mohit and Tornetta III,Firs Edition. Principles of Evidence-Based Medicine. In: Evidence-Based Orghopedics, First Edition. Blackwell Publishing Ltd. 2012.
- Davidson, Terence and Guzelian, Christopher: Evidence-Based Medicine (EBM): The (Only) Means for Distinguishing Knowledge of Medical Causation From Expert Opinion in the Courtroom. Tort Trial & Insurance Practice Law Journal, Vol. 7, No. 2, p. 741, 2012.
- Erlich, George E.: Bulletin of the World Health Organization 2003;81:671-676.
- Gray GE: The philosophy and methods of evidence‐based medicine: an introduction for psychiatrists. Direct Psychiatry 22:165–75, 2002–In the hierarchy of the types of clinical evidence, expert opinion is at the very bottom.
- Gutheil TG, Simon RI: Narcissistic dimensions of expert witness practice. J Am Acad Psychiatry Law 33;55–8, 2005
- McGee, Douglas. Evidence-Based Medicine and Clinical Guidelines. In Merck Manual, Professional Version, July 2015.
- Melhorn, J. Mark, Talmage, James B., Ackerman, William E. and Hyman, Mark H.: AMA Guides to the evaluation of Disease and Injury Causation, Second Edition. 2014.
- Okike, Kanu and Ocher, Mininder S.: Evidence-Based Orthopaedics: Levels of Evidence and Guidelines in Orthopaedic Surgery, In: Orthopaedic Knowledge Update 10 by American Academy of Orthopaedic Surgeons. P 157-165, 2011.
- Sakall, Greg, J.D.: Care and Feeding of Personal Injury Cases‐ the Plaintiff Attorney’s Perspective. Talk at American Academy of Disability Evaluating Physicians, January 15, 2016. Tucson, AZ.
- Shenn Francis, Sumartzis, Dino and Andersson, Gunnar: Nonsurgical Management of Acute and Chronic Low Back Pain. Jour AAOS, Vol 14, Issue 8, Aug 2006
- Schünemann, Holger J, and Bone, Lawrence: Part IV: Evidence-Based Orthopaedics—Evidence-Based Orthopaedics: A Primer: Clin Ortho & Rel Res 413, pp 117-132, August, 2003.
- SEAK: Expert Witness Meeting in Chicago. June 23-35, 2010
- Simon, Robert: Standard-of-Care Testimony. Best Practices or Reasonable Care? J Am Acad Psychiatry Law 33:1:8-11 (March 2005) — Employing evidence-based treatments does not automatically establish that the standard of care has been met.
- Talmage, James: Causation Analysis. Talk at American Academy of Disability Evaluating Physicians, January 14, 2016. Tucson, AZ.
- Wright, James: Levels of Evidence and Grades of Recommendations. AAOS Bulletin April, 2005.