Dear All
I'm slightly worried that this is becoming more complicated than is warranted.
The 2nd edition of "Evidence-based Medicine" by Sackett and colleagues offers the following definition - "Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient values" (p1). Personally, I think that this definition works well.
It seems to me that, particularly among colleagues who choose to be critical of EBM, EBM is seen as a fully comprehensive method of practising medicine. Hence if one practices EBM, this is somehow perceived to exclude patient and physician values, as well as other aspects of good person-centred clinical care. This perception is clearly erroneous, as the definition above highlights very effectively.
Part of the problem, in my view, is that commentators have in a sense parodied EBM in emphasising their own preferences and priorities. Hence we have "narrative-based medicine", and "values-based medicine". For some, this implies making a choice between these. However, this is a naive interpretation, and forms the basis of substantial confusion (as well as some frustratingly misguided editorials and commentaries).
Regarding the earlier query about the literature on values-based practice, I agree that this has been developed predominantly by Bill Fulford from Warwick/Oxford, and his colleagues. I think their work is extremely valuable, and I have continued to point out to Bill the importance of having a broad ranging introductory paper on this topic (as far as I'm aware, most of the references that Bill himself quotes come from textbooks which are unlikely to be easily accessible to many clinicians). The main exception that I have come across is:
M. Petrova, J. Dale, and K. W. M. Fulford. Values-based practice in primary care: easing the tensions between individual values, ethical principles and best evidence. Br.J.Gen.Pract. 56 (530):703-709, 2006.
The other element that has been somewhat neglected in the discussion to date (that is explicit in the definition above) concerns how evidence, values, and narrative are best applied an integrated in individual clinical encounters. Clearly, this depends crucially on the nature and quality of the interactions between patients, clinicians, and possibly also others. This clearly requires the clinician to have expertise. The literature appears to make increasingly frequent references to shared decision-making, although it is curious that this process is very seldom defined, and some references appear inconsistent with the original formulations. Although shared decision-making, appropriately and systematically applied, would be expected to improve outcomes, there is as yet only limited published evidence of this (see E. A. Joosten, L. Fuentes-Merillas, G. H. de Weert, T. Sensky, C. P. van der Staak, and C. A. de Jong. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother.Psychosom. 77 (4):219-226, 2008.).
Kind regards.
Yours
Tom
Tom Sensky BSc PhD MB BS FRCPsych
Professor of Psychological Medicine
Imperial College
Claybrook Centre
St Dunstan's Road
London W6 8RP
United Kingdom
Tel +44 (0)20 8354 8919
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-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Michael Power
Sent: 10 August 2009 05:08
To: [log in to unmask]
Subject: Re: Medical humanism and evidence-based practice may collide
It would be interesting to see how definitions of EBM have changed over time. The "Sicily statement" in 2005 defined EBP as "A Evidence-based practice requires that decisions about health care are based on the best available, current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources." http://www.biomedcentral.com/1472-6920/5/1
This definition replaces "integration of expertise" with "informed by the tacit and explicit knowledge of those providing care". It seems to be saying that research evidence should be applied using expert clinical judgement.
Ben, whn you say "experience is so prone to error that we can never be sure that integration of particular experience with best evidence will in fact lead to optimal prescriptive course", are you implying that there *is* a way ensure that clinical decisions are always optimal? I think this is would be an overoptimistic goal. Clinical decisions are necessarily made with uncertainty about the facts and outcomes. Although experts are subject to the "availability error", as you pointed out, are non-experts better at helping patients make the optimal decision?
Michael
________________________________________
From: donald stanley [[log in to unmask]]
Sent: 09 August 2009 13:52
To: Michael Power
Subject: Re: Medical humanism and evidence-based practice may collide
Dear Michael and Ben,
To see the same scenario, please compare it to the development of ethics
from ancients, through Kant to Moore to Curran to Beauchamp to Veatch to,
you get the point that all of these have struggled to inculcate values with
decisions and none of the strategies: virtue, rules, normative guides, have
proven reproducible and justifiable to all at all times. The discussion
around the definition of EBM or EBP seems to try to mold the clay in one's
own image, at this time, for this instance.
We are still looking for definitive mold.
Donald
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[log in to unmask]
> From: Michael Power <[log in to unmask]>
> Reply-To: Michael Power <[log in to unmask]>
> Date: Sun, 9 Aug 2009 03:26:21 +0100
> To: <[log in to unmask]>
> Subject: Re: Medical humanism and evidence-based practice may collide
>
> Ben
>
> You and I are talking about different issues. You are talking about
> integrating clinical experience with research evidence. I was talking about
> integrating values with clinical practice. I will comment on both issues,
> beginning with integrating clinical experience with research evidence.
>
> Your example shows that there is a problem with integrating clinical
> experience in your sense, which is the obvious interpretation of the phrase
> with research evidence. I interpret the phrase to mean the evidence on a
> particular patient gathered from the history, examination, and special
> investigation; this evidence needs to be integrated with research evidence to
> make a sensible decision about the appropriate clinical management. This
> definition of EBP needs to be rewritten!
>
> Although values always affect decisions, the EBP community has tended to avoid
> looking at how we integrate (or how we should integrate) patient-values with
> research evidence. Sometimes it can be difficult to decide what the
> appropriate decision is. For example, when a pregnant woman has a
> life-threatening disease, and treatment of the disease would be dangerous to
> the fetus. (For a detailed example, see Professor Michael Baum's Samuel Gee
> memorial lecture at https://admin.emea.acrobat.com/_a45839050/p69282078/. Skip
> to slide 36 if you are in a hurry. If you are not in a hurry he has some
> interesting things to say about concepts of holism in orthodox medicine and
> alternative medicine.)
>
> The literature on integrating values with EBP seems to have been largely
> written by Bil Fulford and his colleagues (I would appreciate pointers to
> other authors). The following link is to a paper that gives 10-principles of
> values-based practice and shows how values-based practice relates to
> evidence-based medicine.
>
> http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16954
> 004
>
>
> Michael
>
>
>
>
>
>
> ________________________________________
> From: Djulbegovic, Benjamin [[log in to unmask]]
> Sent: 08 August 2009 21:14
> Subject: Re: Medical humanism and evidence-based practice may collide
>
> Michael, a couple of weeks ago or so, I commented that the "classic"
> definition of EBM ("the integration of best research evidence with clinical
> experience and patient values") is inadequate and should change (if the goal
> is to improve decision-making). A couple of people sent me their personal
> notes asking me to explain what exactly I meant by pointing to the
> impossibility of integration of descriptive aspects of decision-making (e.g.
> personal experience) with normative one (e.g. unbiased evidence) to derive
> prescription for optimal decision-making. I responded with a couple of
> examples illustrating how experience is so prone to error that we can never be
> sure that integration of particular experience with best evidence will in fact
> lead to optimal prescriptive course. For example, I have a colleague who once
> missed brain tumor in the patient complaining of headache. Ever since he has
> used this "experience" to justify ordering imagining studies in all of his new
> patients presenting with headache. As I was rounding this am, I saw tons of
> tests and treatments being ordered based on someone's "experience". In most of
> these cases, it would be difficult to argue that the decisions that were made
> (and are being made in thousands of other patients on daily basis) represent
> an optimal course of action (despite the fact the actions in all of these
> cases met classic definition of EBM). (I am not only talking about heuristic
> and biases that shape everyone's experience...)
> So, I suggest again that we abandon the impossible dream and re-define EBM. (I
> personally favor David Eddy's definition of EBM as a "set of principles and
> methods to
> ensure that, to the greatest extent possible, population-based policies and
> individual decisions are consistent with evidence of effectiveness and
> benefits").
>
> ben
>
> -----Original Message-----
> From: Evidence based health (EBH)
> [mailto:[log in to unmask]] On Behalf Of Michael Power
> Sent: Friday, August 07, 2009 8:29 PM
> To: [log in to unmask]
> Subject: Re: Medical humanism and evidence-based practice may collide
>
> Hi Carlos
>
> Groopman and Hartzband use a definition of EBP that I am not familiar with.
> They say evidence-based practice "aims to put medicine on a firm scientific
> footing; experts evaluate the best available data and develop clinical
> guidelines designed to standardize procedures and therapies".
>
> The second edition of How to practice and teach evidence-based medicine by
> David Sackett, Sharon Strauss, W Scott Richardson, William Rosenber, and R
> Brian Hayns defines EBM as "the integration of best research evidence with
> clinical experience and patient values". The book was published in 2000.
>
> I suspect that the author's chose their narrow definition (thus creating a
> false dichotomy) so that they could make their article more dramatic, for
> example by using the image of medical humanism colliding with EBP. In fact EBP
> coalesced with medical humanism at least 9 years ago. If EBP is imperfectly
> practiced, this is evidence of a problem with the practice, not with EBP.
>
> Michael
>
>
>
>
> ________________________________
> From: Dr. Carlos Cuello [[log in to unmask]]
> Sent: 07 August 2009 16:43
> Subject: Medical humanism and evidence-based practice may collide
>
>
> I would like to hear opinions on this
>
> NEJM: Groopman, Hartzband: Medical humanism and evidence-based practice may
> collide.
>
> http://bit.ly/4YWm3
>
>
> --
> Carlos A. Cuello-García, MD
> Director, Centre for Evidence-Based Practice-Tecnologico de Monterrey
> Cochrane-ITESM coordinator. Professor of Paediatrics and Clinical Research
> Avda. Morones Prieto 3000 pte. Col. Doctores. CITES 3er. piso,Monterrey NL,
> México. CP64710
> Phone. +52(81)88882154 & 2141. Fax: +52(81)88882019
> www.cmbe.net<http://www.cmbe.net>
>
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