Belling the cat

I could not agree more with Dr Bonisteel’s letter “The tyranny of evidence-based medicine.”1 What the evidence-based medical approach dictates might be a bad idea for the patient, particularly in the elderly age group. There are very few good studies conducted in the very elderly. Does tight hypertensive control really prolong life expectancy for a 90-year-old, or just lead to poorer quality of life? Is an implantable pacemaker—complete with warfarin prescription—indicated in a 92-year-old with fainting spells? As complications of anticoagulant therapy increase with increasing age, the chances of dying of a hemorrhage might be higher than the risks of the cardiac problem, whatever it is. We need to reclaim the middle ground of common sense and weigh the evidence to help our patients make the best possible decisions for their Sitz im Leben (setting in life). It appears too many of us make poorly reasoned suggestions because we are afraid of a practice audit or some unknown other peering over our shoulders. Thank you, Dr Bonisteel, for belling the cat.

• Copyright© the College of Family Physicians of Canada