At 10:00 AM 9/5/03 -0400, Djulbegovic, Benjamin wrote:
>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.
I would agree that it is very hard to practice EBM in real-time in this
sense. In real time one often has to follow back on clinical policies or
rules of thumb. However, my hope is that these clinical policies can be
informed by evidence based medicine as much as possible.
First of all, the basic principles of clinical decision making can fit the
EBM paradigm. Even bed-side decisions can be informed by the balance of
benefits and harms to the patients, by understanding that different
patients value benefits and harms differently, and by understanding that
the evidence supporting our knowledge of benefits and harms for a
particular clinical problem may be of varying quality.
Second, EBM can provide, IMHO, the best framework for how we learn how to
practice medicine. There is no reason why every text book chapter, review
article, and lecture should not use the EBM framework.
...............................................................
Roy M. Poses MD
Director of Research, General Internal Medicine
Brown University Center for Primary Care and Prevention
Memorial Hospital of Rhode Island
111 Brewster St.
Pawtucket
RI 02860
USA
401 729-3400
fax 401 729-2494
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