Robin
I guess as Andy's colleague I'm responsible with a number of others for thinking hard about where we have got to with EBP and where we ought to go. Just to say at the start, Andy, I, et al agree with you.
To quote more fully from Dave Sackett's editorial (over 8500 citations I see!):-
"Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer.
Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients."
It would seem that we still concur with that approach, and as others say, what's the alternative?
So, as I've tapped here previously, in the 1990's we needed to develop tightly defined processes to collate research; we now have those and that now goes increasingly into national evidence-based guidance. However, EBP doesn't end there. There's been amazing progress with both methodologies and delivery of the evidence, but if I was to gently offer a criticism of my own small part and much greater contributions of many others it would be that we've often stopped at that point.
A second translation is required to turn that national guidance into local policies and systems. If you doubt me consider the current discussions everywhere about revising local arrangements for the treatment of patients with atrial fibrillation and VTE now we have newer agents to consider alongside warfarin and aspirin. There's very little research effort directed at how to tackle that translation from national to local, and hence little to guide those with the difficult task. And we haven't stopped there. Of course we all concur with the synthesis of "individual clinical expertise with the best available external clinical evidence from systematic research". That third translation is crucial and despite the warning that EBM isn't "cookbook medicine" I often see it applied as such. Arguably we haven't devoted enough effort and research to help the third and I would argue most complex translation (from local policy to the decision making with or for an individual), certainly we haven't if we compare that with effort directed to SR, MA and guideline methodology and their production. Declaring happily my own bias, we teach consultation skills lots. But we rarely teach decision making explicitly. There's a metaphor here:- “This long history of learning how not to fool ourselves is, I’m sorry to say, something we haven’t included in any particular course that I know of. We just hope you’ve caught on by osmosis." Richard Feyman, 1965 Nobel Laureate, Physics
So Andy, I and others sign up completely to the "Evidence-based medicine is the integration of best research evidence CLINICAL EXPERTISE AND PATIENT VALUES." (your emphasis).
The great thing is that these ideas are indeed now "popping up" in more places - I've never been busier. Debate is always healthy, but we don't disagree. We don't think we need EBM2 or EBP2, we need a concerted effort on how best to undertake the 2nd and 3rd translations- to match the efforts of the last 20+ years largely directed at the 1st.
Best wishes to all
Neal
Professor Neal Maskrey
Consultant Clinical Adviser, Medicines and Prescribing Centre National Institute for Health and Care Excellence Ground Floor Building 2000 Vortex Court | Enterprise Way | Wavertree Technology Park | Liverpool L13 1FB | United Kingdom
Tel: +44 (151) 353 7729 | Fax: +44 (151) 220 4334 Honorary Professor of Evidence-informed Decision Making, Keele University, Staffordshire. ST5 5BG.
Web: http://nice.org.uk
-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Harbour Robin (HEALTHCARE IMPROVEMENT SCOTLAND - SD039)
Sent: 25 October 2013 08:27
To: [log in to unmask]
Subject: Re: Criticisms of EBM
I have seen Andy's argument pop up in various forums recently. It seems to me to be based on a mistaken view of what EBM is all about. I refer back to Dave Sackett's 1997 definition:
"Evidence-based medicine is the integration of best research evidence CLINICAL EXPERTISE AND PATIENT VALUES." (my emphasis)
Look at the principles behind GRADE to see that it is as true now as it was then.
Robin
Robin T Harbour | Lead Methodologist
Scottish Intercollegiate Guidelines Network Delta House | 50 West Nile Street | Glasgow G1 2NP
t: 0141 227 3298 Internal: 8714
e: [log in to unmask]
Web: www.healthcareimprovementscotland.org; www.sign.ac.uk
Twitter: @online_his; @signguidelines
Facebook: www.facebook.com/healthcareimprovementscot; http://www.facebook.com/SIGNGuidelines
Youtube: http://www.youtube.com/user/SIGNGuideline
The Healthcare Environment Inspectorate, Scottish Health Council, Scottish Health Technologies Group, Scottish Intercollegiate Guidelines Network and the Scottish Medicines Consortium are part of Healthcare Improvement Scotland.
The Scottish Intercollegiate Guidelines Network is part of Healthcare Improvement Scotland.
-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Andy Hutchinson
Sent: 24 October 2013 14:09
To: [log in to unmask]
Subject: Re: Criticisms of EBM
Hi Anoop
>> Some of his numbers, like "only 4% of the medical mistakes are due to shortcomings in knowledge" seem to be a bit far-fetched.
Well, I don’t know about the whole range of medical errors, but in a retrospective US audit, published in 2005, 100 cases of diagnostic errors were used to determine the significance of the roles that cognitive and system-related factors play in diagnostic errors. Diagnostic errors were rarely caused by inadequate knowledge (in only 4 cases, each concerning a rare condition, i.e. 4%. Seven cases involving inadequate skills involved misinterpretations of X-ray studies and electrocardiograms by non-experts). The most common reasons for misdiagnosis were system-related factors, cognitive-related factors or a combination of both.
See http://www.npc.nhs.uk/rapidreview/?p=4098 for a review.
To be a bit provocative, IMHO the greatest single fallacy that EBM-advocates can fall prey to is that propositional knowledge ('knowing that') is all that is required to ensure good care (appropriate resources aside e.g. actually being able to offer an expensive but evidence-based treatment) – that it will automatically translate into procedural knowledge ('knowing how and what to do') and that people will automatically do it. If that were the case, uptake of new evidence would not be an issue, and innovation would flow into practice like water through a pipe. But does that happen? I think not!
As Douglas Adams said, 'people are a problem'. Knowing the evidence is necessary but it is by no means sufficient. Adoption of evidence into practice depends ultimately on decisions to change made by individual people. Healthcare does not and cannot operate ‘like a well-oiled machine’. It is provided for individual people (and their carers) and by a number of teams of individual people. All these people have the freedom to act in different ways that are not totally predictable, and whose actions are interconnected and affect those of others. Personal mental models, relationships and interpersonal influences, as well as organisational matters, are therefore critical factors. All these factors interrelate and affect one another in complex and evolving ways which are not predictable and may be surprising. See http://www.npc.nhs.uk/merec/therap/other/merec_bulletin_vol22_no2.php, where colleagues and I develop this argument further and suggested some approaches in response.
Cheers
Andy
Andy Hutchinson
Medicines Education Technical Adviser
Medicines and Prescribing Centre
National Institute for Health and Care Excellence Ground Floor Building 2000 | Vortex Court | Enterprise Way | Wavertree Technology Park | Liverpool L13 1FB
Tel: 07824 604962
Web: www.nice.org.uk/mpc
email: [log in to unmask]
-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Anoop Balachandran
Sent: 24 October 2013 13:35
To: [log in to unmask]
Subject: Criticisms of EBM
Does anyone have any comments on Yvo Smoulders criticisms of the EBM approach.
http://www.youtube.com/watch?v=PRiSlU1ucqI
"
I don't understand Dutch so I couldn't find out where he got most of his numbers. Some of his numbers ,like "only 4% of the medical mistakes are due to shortcomings in knowledge" seem to be a bit far fetched.
Some if his commented translated by another person:
"Even if you consider epidemiological to be true, the best case scenario is that epidemiological evidence is external valid in 40% of the patients with a complaint, in the worse case scenario that is 0,001% Thus, all-and-all it is pretty weak:
1/3 is studied
1/2 is true
It is only external valid to 10% of your patients You probably don’t know more then 50% of all relevant evidence THUS 1/120 of your therapeutic actions are based on evidence!
If you compare hospitals who score high on quality care, vs. Hospitals who score low on quality of care, the critical factor does not appear to be EBM on epidemiological studies. The critical factor seems to be the fact that the better hospitals are known for their a good “culture” (literally: “soft variables”) On accountability: Only 4% of the medical mistakes are duet o shortcomings in knowledge. Rest is clinical reasoning, lack of commitment, lack on communication."
__________________________
Delivered via MessageLabs
__________________________
The information contained in this message and any attachments is intended for the addressee(s) only. If you are not the addressee, you may not disclose, reproduce or distribute this message. If you have received this message in error, please advise the sender and delete it from your system. Any personal data sent in reply to this message will be used in accordance with provisions of the Data Protection Act 1998 and only for the purposes of the Institute's work.
All messages sent by NICE are checked for viruses, but we recommend that you carry out your own checks on any attachment to this message. We cannot accept liability for any loss or damage caused by software viruses.
http://www.nice.org.uk
********************************************************************************************************************
This message may contain confidential information. If you are not the intended recipient please inform the sender that you have received the message in error before deleting it.
Please do not disclose, copy or distribute information in this e-mail or take any action in reliance on its contents:
to do so is strictly prohibited and may be unlawful.
Thank you for your co-operation.
NHSmail is the secure email and directory service available for all NHS staff in England and Scotland NHSmail is approved for exchanging patient data and other sensitive information with NHSmail and GSi recipients NHSmail provides an email address for your career in the NHS and can be accessed anywhere
********************************************************************************************************************
__________________________
Delivered via MessageLabs
__________________________
The information contained in this message and any attachments is intended for the addressee(s) only. If you are not the addressee, you may not disclose, reproduce or distribute this message. If you have received this message in error, please advise the sender and delete it from your system. Any personal data sent in reply to this message will be used in accordance with provisions of the Data Protection Act 1998 and only for the purposes of the Institute's work.
All messages sent by NICE are checked for viruses, but we recommend that you carry out your own checks on any attachment to this message. We cannot accept liability for any loss or damage caused by software viruses.
http://www.nice.org.uk
|
