As someone who is engaged full-time in evidenced-based technology
assessment, I certainly sympathize with Dr. Djulbeqovic's point. When
it takes us months of full-time effort by a team of information
specialists and analysts to adequately assess some topics, I can't
imagine how a practicing physician or nurse, with little training in
information science, research design, analysis and statistics, can find
time to do justice to some of these problems in an evidence-based way.
Furthermore, for each individual clinician around the world to be
attempting to do this on their own, is incredibly inefficient.
At the risk of beating the drum for my own profession, it seems fairly
obvious that in this information age there is a strong need for
full-time professional EBM practitioners whose services are somehow made
available to clinicians in the trenches. These EBM analysts might be
associated as consultants or full-time members of departments, or on the
staff of the medical library, or, more efficiently, centralized in
government agencies or independent organizations such as my own.
Expecting individual physicians to do adequate searches, meta-analysis,
decision modeling, etc. is like asking everyone to make their own car
repairs, or a more apt analogy would be to require patients to look
everything up themselves and perform their own treatments. Ultimately
the clinician at the bedside (and the patient, of course) must make the
decisions, but much of the information needed for the decisions could be
supplied by EBM specialists. This requires a financial commitment, but
such a redirecting of resources might turn out to be more cost-effective
in the long run.
David L. Doggett, Ph.D.
Senior Medical Research Analyst
Health Technology Assessment and Information Service
ECRI, a non-profit health services research organization
5200 Butler Pike
Plymouth Meeting, PA, USA 19462
Phone: (610) 825-6000 x5509, FAX (610) 825-6834
e-mail [log in to unmask]
-----Original Message-----
From: Djulbegovic, Benjamin [mailto:[log in to unmask]]
Sent: Friday, September 05, 2003 10:01 AM
To: [log in to unmask]
Subject: Re: Evidence based teaching
I think we should not be so quick to dismiss the criticism about the
value of EBM that the recent e-mail raised. After teaching various
courses on EBM (since 1997) and the attempts to integrate it in my own
practice, I am not so sure how FEASIBLE is to teach EBM at bedside.
Medicine is primary problem-solving and decision-making exercise. While
we have all argued over the years that understanding the nature and
quality of evidence etc is a key to practice of medicine, the original
EBM paradigm (ask-search-appraise-decide) is simply very difficult to
apply in practice. The primary reason, of course, is time-constraint.
When my team has 20-25 of acutely ill patients on the ward and admit and
discharge every day 3-7 patients, it is impossible to approach
decision-making and problem-solving in EBM structured way. So, in
practice, instead of serving as a facilitator, I end up spoon-feeding
that necessary knowledge, which students, residents, fellows are
supposed to discover on their own. When I don't know the answer, then we
call consultants to help us with our questions. We simply don't have
time to go through EBM process (despite the fact that I work in
high-tech surroundings with computers at every corner, linked to any
database you can think of...of course, we have journal clubs, teaching
conferences, educational objectives, assignments and all that...we even
do decision models, meta-analyses, understand the differences between
normative vs. descriptive vs. prescriptive decision making etc).
However, at the end of the day, it is CONTENT (i.e. content-specific
expertise) that wins the day and not the process, or method-oriented
approach which EBM paradigm promised. That is, the consultants (from the
various disciplines who may or may not be of EBM kind) are the one whose
advice you will follow (99% of time) regardless if that advice is EBM
formulated or not. Several years ago I have been dreaming (and still do)
that we will be able to identify all high-quality evidence (in my field,
hematology and oncology), which we will then pre-processed and have at
finger-tips at the bedside. Other folks have done the same in other
areas of medicine. While I am still hoping that "thrill is not gone",
EBM (and related initiatives including decision-analysis) has to face
the key aspect of clinical medicine: LIMITED TIME FRAME FOR
DECISION-MAKING UNDER CIRCUMSTANCES OF UNCERTAINTY.
I am hopeful that this e-mail, which I wanted to send for some time, but
did not have time, will help stimulate some constructive debate.
Benjamin Djulbegovic, MD,PhD
Professor of Oncology and Medicine
H. Lee Moffitt Cancer Center & Research Institute
at the University of South Florida
Department of Interdisciplinary Oncology
SRB #4, Floor 4, Rm #24031 (Rm# West 31)
12902 Magnolia Drive
Tampa, FL 33612
Editor: Cancer Treatment Reviews (Evidence-based Oncology Section)
http://www.harcourt-international.com/journals/ctrv/
e-mail:[log in to unmask]
http://www.hsc.usf.edu/~bdjulbeg/
phone:(813)979-7202
fax:(813)979-3071
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