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Thanks Paul, I agree that universal training in EBM (evidence based medicine/practice) is the most important need that it faces today as a sapling to grow into the tree that it deserves to in future.

 

However one must ensure that the training is done in realistic circumstances in the workplace. This I find has been emphasized even by the EBMWG way back since its inception along with other papers over the years that reflect its outcome based efficacy in those settings.

 

Coming to the question of how the EBM tree would look in future I wish there were more descriptions of the EBM process (that is right now active but remains undocumented in most health care giver workplaces—their day to day tryst with utilizing/applying EBM etc).

 

 Most of the papers available on EBM today, concentrate on outcomes and leave us guessing about the circumstances and details of their genesis. This in the past was due to space constraints in paper journals but in the paperless universe of the future one may even hope to look at the lives of all the 4444 people swallowing the anti-lipidemic (later thought of as anti-inflammatory as well) and through their life details appear at an understanding of how their lives were transformed by the pill (and not just if/when they died).     

 

I am aware its too much of an undertaking {even if the life/file details of the 4444 people in the single paper was available on the web for free access we would need extra RAM on our skull tops (brains) to gorge on and digest that kind of sundry information}. Perhaps we might have that as well in future?

 

One can also look at the past to understand future. In the past (200 years?) the kind of information access that I am talking about did exist in the skull tops of many all knowing and all powerful family physicians (in the absence of the specialist—if at all the only competition was the barber surgeon).
 
The past wise physician's anecdotal wisdom although of negligible benefit in a present global society was of immense value in their local communities where they were seeped in information about the details of their patient's lives that gave them a non mathematical/non generalizable but perhaps equally fair impression of what suited their individual patient needs.
 
Most of their treatments by today's standards would be deemed palliative but then one might witness the same happening to present day evidence based treatments in future (even the present heirarchy of weighing evidence may change with the discovery of something better than the RCT/Syetemic review).
 
Its always inconceivable how some paradigm can replace another untill it happens as a breakthrough and the cycle continues.

 

The greatest problem in EBM today is applying evidence to the individual and that is what has made EBM a meeting ground for qualitative and quantitative researchers/observers alike and very often it transforms into a battle ground with various parties accusing each other of microfascism, shooting expletives like post positivists (aimed at aeriel nosed quantitative EBMers), post modernists (targeted towards un-understandable qualitative researchers).

 

In future I hope the EBM tree would have a more aesthetic/fractal symmetry and not appear bowed down to one side as some perceive it now.
 
Rakesh Biswas

 

 


On 10/24/06, Paul Glasziou <[log in to unmask]> wrote:
Dear Ornissa
An interesting question. It might be useful to break this into 2 parts: (a) sorting out the information mess and (b) bedside use of evidence by clinicians. Improving (a) will help (b) but will only ever be a part of the "solution".
(a) Its useful to consider Brain Haynes's 4S model: Studies, Syntheses (systematic reviews), Synopses (such as Clinical Evidence), and Systems. With around 90 trials per day and 4 new reviews, we will continue to have an information overload. Trials, and other evidence, grows at a faster rate than it is synthesised in systematic reviews, and the reviews have large gaps in usability. So the 4S is improving but still not matching the rate of growth and needs to solve several presentational problems to make the syntheses, synopses, and systems directly usable in clinical settings. It will happen, but only gradually.
(b) Even if the mess of (a) is sorted, so evidence is on tap at the point of care, we still need several steps. First, clinicians will need to distinguish good from poor evidence. Anecdotally I have heard that the growth in clinicians use of pharmaceutical company websites outstrips use of good evidence resources. Second, clinicians will still need to be able to individualise and contextualise that evidence.
So what needs to happen to achieve this? First, we should encourage and assist the growth of good evidence resources. Second, every medical (and nursing, and physiotherapy, etc) school needs to provide excellent training in EBM at the undergraduate and postgraduate level. This means not just having heard about statistics and trials, but good knowledge, skills, and (mostly importantly) attitudes in the use and application of research. That is a slow but necessary shift that will take decades. Which reminds me of the saying: The best time to plant a tree is 20 years ago, the second best time is today!
Best wishes,
Paul Glasziou


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Greetings
Could I please have comments on peoples thoughts/model on the future of EBP,
?Different levels of EBP Practice, some aimed at practicing Clinicians to the Clinicianswriting systematic reviews/CPGs.
Please let me know,
Cheers,
Ornissa Naidoo
Clinical Educator
Loganbeaudesert Health Service District
Australia


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Paul Glasziou
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