In message <CF1AA81579F2D211B64600805FFE91E102383C32@prc23nts>,
Sontheimer, Daniel MD <[log in to unmask]> writes
>Agreed, I think EBM next phase is to grow to a level, where it is used as a
>lens/filter with which to guide the practice of Medicine.
>Combining the work of EBM with reflective practice (clinical jazz in
>Slawson's and Shaughnessy's work), can help move us forward.
>
>The biggest problem with EBM is the attempts to represent "the truth", as
>being solelly defined by EBM. Thus, you now have drug reps, and other
>soliciters approaching everything with "evidence-based" perspective.
>
>Perhaps there is a more post-modern perpsective for EBM, I think it is in
>combining with reflective practice, and then we can avoid this bouncing
>around of "the truth"
>Dan
>
>
You are right. I think the first phase of EBM was the working out of how
research findings could be applied to clinical practice using
epidemiological principle, and the realisation that clinicians had both
the right and duty to question established practice.
It has now (in the UK at any rate) been largely hi-jacked by expert
groups who have adopted it as a sort of mantra to justify and give more
weight to decisions they would have made anyway (see the recent
controversy in the BMJ and rapid responses about the National Institute
of Clinical Excellence (NICE)).
While there is a minority grassroots movement that is attempting to
encourage evidence-based practice by coal-face clinicians and managers
(such as, for example, through the London, Oxford and our own Durham
workshops) there is not nuch widespread support at senior levels for
ordinary clinicians to acquire these skills - they would rather keep
them to themselves (although as the NICE imbroglio shows, not
necessarily with any great degree of competence). This may well be
because senior clinicians and managers, in their hearts, don't really
want more junior people to be able to make their own decisions according
to the evidence and their patients' needs, because it threatens the
establishment's power and influence (see Lipman, T. Power and influence
in clinical effectiveness and evidence-based medicine. Family Practice
2000;17:557-563).
The other major issue is: once you have learned the skills of EBM, how
do you actually use it in clinical practice? Some work has been done on
ways of accessing evidence quickly in the clinical setting (eg the
'evidence cart' work). Most UK GPs now have internet access at their
desks and some are beginning to make tentative experiments on including
the EBM process within the context of routine consultations. It is
becoming clear to me that this is a huge field for research, and that
EBM has to be integrated into an already sophisticated consultation
process rather than replace it with something quite different.
So we need to ask: is it feasible? how much time do we need? what
prompts us to ask questions and do searches, given that we are never
going to have the time (nor do we need) to do this in every case? how do
we involve the patient in this process? how do we judge the extent to
which patients want to share decision making? do common scenarios such
as sore throats (in which we will soon know the evidence by heart!) lead
us to develop "EBM scripts", in which the scenario is learnt and acted
out repeatedly?
And so on.
So I think we are beginning to understand that learning the basics of
EBM is only the beginning and that we are entering upon a time in which
we have to discover the way it can be used and what impact it will have
upon practice. Maybe that is why we haven't been so vocal recently - we
are thinking!
Toby
--
Toby Lipman
General practitioner, Newcastle upon Tyne
Northern and Yorkshire research training fellow
Tel 0191-2811060 (home), 0191-2437000 (surgery)
Northern and Yorkshire Evidence-Based Practice Workshops
http://www.eb-practice.fsnet.co.uk/
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