Guthrie bruce suggests that established practitioners might want to ask:
"Compared to those who do not, do doctors who practice EBM have
better outcomes for their patients?"
before they ask the more specific question:
"Should I practice EBM?"
and concludes that "...this isn't easy to answer because the
range of conditions is so large and the range of possible outcomes
even more so..." He then sets to to look for "the evidence for evidence
based medicine" and lo & behold finds there is very little compelling
evidence for established doctors but some evidence for medical students.
There are deeper issues going on here which I feel need to be addressed:
1) The trivial questions ask: Is finding "evidence for evidence" a
pointless circular exercise? On what basis would one prove that "the
concept of evidence" is valuable? Is turning to evidence as a basis for
clinical practice an act of faith?
2) The more serious question asks: how would one categorise a doctor who
did not practice EBM?
I tried to imagine such a doctor. A real gp came to mind - one of those
gps who never attends any cme, who only reads consultant letters for
education, attends the occasional drug company lunch, and learns "from the
wealth of experience from patients" (a quote from such a gp). "Evidence"
to this gp's way of thinking does not arise from formal studies, but from
personal experience. This gp would never frame a question so that he or
she could find an answer looking up the latest articles via the many
available medical data bases - no matter how easy the process. This gp
could go through 30 years of general practice, never getting sued by a
patient,never coming face to face with an academic gp, and being able to
sell a happy practice on retirement. This gp practices experience based
medicine and happily interchanges the concepts of "evidence" for
"experience".
As of about 3 years ago, the accrediation requirements for gps in new
zealand made this kind of doctor disappear (which means we could never
compare a non-ebm doctor with an ebm doctor). The formal accrediation &
re-accrediation processes force EBM onto the doctor's way of practice
(doing an audit for example). I imagine the resistance of about 500 gps in
nz to the reaccrediation process involves having to swallow that bitter
tasting medicine called EBM.
One is reminded of all those historical examples where people were forced
to change their faith. My suggestion for progess in EBM is to use EBM when
teaching students and show older doctors that EBM works by way of example
-> A method used by jesuits (& other religious orders) when they wanted to
show their way of life was better than somebody elses.
Signature:
Dr Marjan Kljakovic
Senior Lecturer in General Practice
Wellington School of Medicine
PO Box 7343, Wellington South, New Zealand
(64) 04 385 5999, Fax (64) 04 385 5539
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