COMPLETENESS OF EVIDENCE.

In evaluating the evidence, there

is one additional consideration for clinicians. The medical literature
is skewed by publication bias. Such selective publication can distort
the evidence available in the medical literature, compromising sys-tematic reviews
and meta-analyses, impairing evidence-based clinical
practice, and undermining guideline recommendations. Studies have
suggested that less than half of the trials registered in ClinicalTrials.
gov, the Internet-based registry of clinical trials managed by the U.S.
National Library of Medicine, had been published.
21
Many trials that
are published lack complete safety data.
22
Data that are not published
can have important public health implications, as was demonstrated
in the case of rofecoxib (Vioxx).
23
Clinicians are handicapped by not
knowing what is not in the literature, and should at least be aware that
information on the safety and effectiveness profile of interventions
may not be complete. This unfortunate fact heightens the uncertainty
around treatment decisions.
ACCURACY OF TEST RESULTS. An important aspect of clinical
decision making is the validity of the primary information on which
the decisions are based. Clinicians need to ensure that the evidence
is coherent and consistent. Does the evidence, in its totality, make

sense? Clinicians must be prepared to review the primary data, par-ticularly when
information is inconsistent. Errors can occur in analyz-ing, interpreting, or reporting
results. Excellent clinicians recognize
the possibility that the information with which they are provided is not
correct.
Cognitive Errors
Even with good information, cognitive errors can undermine clinical
decisions.
24
Some examples of these errors are described below.
HEURISTICS OR RULES OF THUMB. Clinicians tend to rely