If you have ever been confronted by an Evidence-Based Medicine (EBM) “zealot,” you know that we can be quite persistent.

We EBM zealots (like our religious counterparts) have become accustomed to the knee-jerk resistance, and so we are prepared for a potentially long conversation – even multiple conversations. When my newest “target” begins to show the telltale signs of resistance, I take a deep breath because I’m in it for the long haul. Recently, while having a conversation about the lack of evidence to support the use of epinephrine in Advanced Cardiac Life Support, I noticed my “target” colleague was conspicuously exhibiting the Kübler-Ross model for the Five Stages of Grief.

As he attempted to defend the tradition of using epinephrine, I watched him come to terms with the implications of acknowledging the importance of assimilating high standard, rigorous EBM into his clinical approach. This could literally change most of what we do as physicians. I was struck by how similar it was to observing a mourner.

Stage 1: Denial

“This can’t be true,” and “I was taught that it works!”

At first, it seems impossible that American Heart Association Guidelines have been repeatedly shown to have no efficacy other than to lengthen ICU stays before death or lead to higher numbers of discharged patients with poor neurological outcomes. However, if we acknowledge this – if we swallow that bitter pill – we may be consigning ourselves to confronting almost every facet of what our mentors taught us. This is unpleasant, cognitively scary, and even painful. The reflex is to kick back and defend unproven but dogmatic practices. “It makes sense theoretically,” or “it should work” are typical replies.

“Very smart people – people smarter than you – believe in this” and “I’ve seen it work myself” are two more expected responses, both problematic. The former replaces critical thinking with fealty and blind faith; fine for a beginning student but not for an advanced student or practicing doctor. The latter relies on anecdote, which, as has been noted by others, is not data (even in plural, unless it is somehow quantified and measured). We go into Denial because it is painful to accept that we may have had excessive trust in authority of our admired teachers and feared exams.

Stage 2: Anger

Anger in confronting EBM zealots comes in two forms: First, “Why did I waste all this time learning false things?” is a very understandable and appropriate emotion. Second, “targets” sometimes attack the messenger, not the message. One typical response ascribes arrogance to the EBM zealot. “How can you have the audacity to say that the AHA is stupid?”

This is a defense mechanism against the next logical inference: “if the EBM zealot thinks the AHA is acting stupidly, he must think I’m both stupid and a sucker.” No one likes being told he or she is an automaton. So EBM zealots are demeaned as pushy and arrogant, instead of well-meaning, ethical, curious adult learners who focus on patient-centered outcomes. While some of us may exhibit some or even all of these qualities, the former should not disqualify the latter.

Stage 3: Bargaining

“This treatment can’t be studied,” they might say, which is true in some cases. That is not my focus here. I’m more interested in the low-hanging fruit. If a medical intervention can be studied, and it has been (such as epinephrine in pre-hospital ACLS), why do so many recoil against the data and the conclusions which naturally follow? More bargaining ensues. “Maybe they needed a bigger sample size.” “If I look at the data just right, maybe I can identify subpopulations for whom the intervention works or confounders that discredit this study.” While true, it is unlikely that investigators are under reporting positive effects of medical interventions. If the “target” exhibits this kind of careful data analysis toward a research paper whose data discredit a historical best-practice, an inflection point may have been reached.

Such critical thinking implies genuine inquiry and data-driven curiosity possibly leading to the adopting of the anti-dogmatic pro-data approach that the EBM zealot hopes to spread.

Stage 4: Depression

“Was everything I was taught all for nothing?” “Are we no better than the charlatans from days of yore?” “Were my teachers lying or incompetent?” “Are the boards filled with drivel?” “Are all of my colleagues a bunch of suckers? Am I one?” There can be an understandable sense of hopelessness and bemusement as the new EBM convert discovers more examples of futile treatments in our practice. Further, the convert may find that pointing out these unpleasant truths is frequently met with opposition and even alienation. Indeed, depression may be appropriate and can signify the point-of-no-return for the “target” turned “convert” or perhaps “zealot.”

Stage 5: Acceptance

The target stops fighting the urge to cling to dogmatic teachings that have been discredited in the primary research literature. Now a convert, this person seeks data to support interventions and asks important questions about the quality and applicability of the literature. The target may actually become an EBM zealot, participate in well-designed, adequately powered research, and approach official guidelines and newly minted research papers with a wary eye. Noticing that few physicians engage in this practice can – fortunately or unfortunately – lead the new EBM zealot back to Anger (Stage 2). However, this may be a “good” Anger, if sublimated into talking to other physicians and students about rational medicine and patient-centered outcomes. On the other hand, the target may enter into the Acceptance stage resigned that “this is just the way things are” and “there is nothing I can do to change it.”

These doctors may do nothing to impede either the EBM zealots or those who cling to historical practices. They sit out the debates. This is unfortunate and possibly the most discouraging outcome. Complacency in the face of alarming data is a more nefarious entity than ignorance. Unlike in classic Kübler-Ross thinking, the Acceptance stage can be positive or a negative development.

The irony is that if I’ve been convincing here, then I have not been – in a sense. Yes, my reasoning may be sound enough to compel you toward my way of thinking, but the Five Stages of Kübler-Ross grief itself has never been validated. It is a made-up construct. Some critics say it does not exist. Some grievers skip steps or go out of order, exhibiting some or none of the stages. But based on the appearance of this article in this periodical, if I had not written this paragraph, many readers may well have assimilated the attractive idea that physicians go through the stages of Kübler-Ross grieving when revising previously held dogmatic beliefs. This has never been tested; the null hypothesis says they don’t.

Dr. Faust is an emergency medicine resident at Mount Sinai Hospital, New York, and tweets about mE.D.icine and classical music @JeremyFaust.