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EVIDENCE-BASED-HEALTH  August 2006

EVIDENCE-BASED-HEALTH August 2006

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Subject:

Re: Why is EBM Important?

From:

"Bill Cayley, Jr" <[log in to unmask]>

Reply-To:

Bill Cayley, Jr

Date:

Thu, 10 Aug 2006 08:43:24 -0700

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (357 lines)

Paul

I think this is a great summary - you've pulled
together comments from a couple of different angles,
and I think it's great to get this conversation out
for wider distribution. Really, after all, one of the
underlying questions is how to take the idealistic
goals of EBM, and translate them into real practice.
This synopsis gives a good overview of the issues
involved in that translation that people have
identified.

Bill C

--- Paul Glasziou <[log in to unmask]>
wrote:


---------------------------------
    Dear All,
I thought the recent discussion on Why EBM raised many
excellentpoints: it was so good I thought we should
publish a digest of this inthe EBM Journal. So can I
ask the list members (and particularly thequoted folk
- Bill Cayley, Amit Ghosh, Neil Maskrey, Stephen
Perle,Sachin Dave, BenDjulbegovic, Rakesh Biswasand
Rob Mullen)to look at the article and get any feedback
to me by next Monday at thelatest?
Thanks for all the contributions.
Paul Glasziou
------
Why is EBM important?
I’m sure readers of the Evidence-Based Medicinejournal
havea variety of reasons for subscribing. But most of
you would assume EBMisimportant to clinicians.
Recently Olive Goddard (the manager at theCEBM in
Oxford)forwarded this questionto the Evidence-Based
Health Care list: "Could you please tell me whyEBMis
important? Can a physician practice medicine without
knowing EBM?"Theemail list has over a thousand
subscribers and many had an opinionabout thisquestion.
I will abbreviate these to highlight some of the
threads, butyou canread the full text on the list.

 

Bill Cayley kicked us off by saying that: “Here’s my
answer – along the lines oftheintroduction I give our
medical students: In medicine, we arecontinually
makingdecisions, and if medicine is to be a science or
a “learned”profession, weneed to think critically
about HOW and WHY we make those decisions.There are
anumber of potential approaches to making decisions:
1) Tradition(“we’ve alwaysdone it this way”, “my
teachers did it this way”); 2)
Convention(“everyoneelse always does it this way” –
ie, going with the crowd), 3) Belief orDogma(“I
believe the natural way is best”), 4) “Evidence-based”
– that isbased onsome sort of systematic assessment of
evidence.

Further, Idiscuss with mystudents the fact that you
can look at evidence as simply ANYobservation aboutthe
nature of the world. In the medical literature, we
call a single,isolatedinstance of something an
“anecdote” (or, if published, a “case report”).  If
you take a bunch of observations and groupthem
together, we have a “case series”. You can go on up
from there in terms of the rigor,systematization,
andthoroughness of evidence evaluation up to the
double-blinded randomizedtrialor the meta-analysis. 
ALL observationscan be considered “evidence” – it’s
just a matter of asking what theQUALITY ofyour
evidence is.”

 

A great start to the discussion. The
textbookdefinition(roughly) says that EBM = clinical
expertise + patient values + bestresearchevidence.
That last element is tricky and requires search
skills,resources,and the critical examination
suggested by Cayley. Of course, patientsarealways
surprised that clinicians are not already using “the
bestresearchevidence”. So why doesn’t that happen?
Well Amit Ghosh chimed in andaddedthat: 

“until Sackettand Guyatt'sintroduction of the
discipline of EBM I am not sure if we did look
intostudiesas critically as we do now. The medical
curriculum was deficient inthis aspectand even now in
many places only catching up. The bigger question
thatremains iswhether teaching the basics of EBM would
be an answer to all theproblems whenthe physician has
little control on anything else. The over
simplisticway tothink is that critically reviewing an
article would provide the bestevidencefor the patient
(we don't make that promise any more). The
issuessurroundingsuccessful implementation of EBM in
medical schools  arefar more complicated with mega
secondarysources of information like UpToDate and
others coming to thephysicians rescuemore frequently
than the complicated juggernaut of negotiating
BrianHaynes’ 4Smodel (Systems, Synthesis, Secondary
sources, and Studies). In allfairnessdespite it great
precision and depth, Cochrane reviews are hard
todigest inthe time that any practitioner will ever
have (average review is 50pages). Thefinal blame
always falls in our inability to fulfill the promise
thatmany ofus make that teaching EBM will it solve
most the problems.

In all itssimplicity andcomplexity EBM has unraveled a
whole set of issues confronting medicaleducation and
medical practice and we thank the McMaster Group for
thisstepforward. How we finally use EBM in an uniform
fashion, all around thegloberemains the experiment for
the near future.

 

 

So EBM is important, but its practice needs toevolve.
Thereare still critical barriers in our evidence
resources and deficienciesin manymedical curricula. As
Bill Cayley later added “...some perceived the promise
that EBM would answer all our problems (ifthatpromise
was ever there) was overstated. It's one thing to know
we needevidence, it's entirely different to a) FIND
the evidence, and b) APPLYit.”

 

So how and where does EBM fit in with
currentimportantelements of the medical curriculum? It
can be seen as an overlapbetweenresearch (often
covered in statistics) and decision making
(oftencovered inethics). Someone once suggested the
key ethical decision makingprinciples areexpressed  by
the French Revolution mottoof Liberte (autonomy),
Egalite (Equity or justice), and
Fraternity(Benevolence). Neal Maskrey considered how
EBM fits this framework whenhesuggested: “We ask
people to firstdescribetheir ethical framework for
decision making. Hopefully we get tosomething
likethis:

(i) First do noharm(Safety) - well done Hippocrates,
but what next?

(ii) Try and dogood -efficacy and effectiveness,

(iii) Justice /Equity -most health care practitioners
and especially students have an innerdrive
forfairness, and it's entirely legitimate therefore to
considerbenefits:cost froma population as well as
individual perspective,

(iv) Patientautonomy (it'scalled assaulting patients
if you don't ask the patient and respecttheirwishes).

So what sort ofevidence wouldyou expect people to use
to populate these four ethical domains andthen
weightthem up when decision making? Obviously we could
just do what otherstold us orwhat we've always done or
what we intuitively believe. But PATIENTSHave theright
to expect us to use the best evidence that's available
to helpthem. Weare here to serve our patients and we
therefore need to strive to avoidfallinginto the traps
of the cognitive biases e.g. of believing what we
see,or havedone before and think works, or what others
tell us, or indeed ofbasing ourpractice on
pathophysiological mechanisms where better evidence
exists.Whatapproaches can be used to make decisions
(weigh up the values of thefourdomains)? This is in my
experience best debated over a very good dinner(with
adecent bottle of wine for those who wish!).

 

So EBM is important as a critical element
ofmedicaldecision making and medical ethics. Given
most treatments have someharm, or atleast an
opportunity cost, an initial concern of EBM has been
to avoidusingineffective interventions – and hence
follows the dictum of firstly dono harm.However,
Stephen Perle reminded us of the different flavours
of"evidence" include historical attributions by
pointing out that:

“primum nonnocere wasfirst in the English literature
in 1860, with attribution to theEnglishphysician,
Thomas Sydenham (1624-1689). The quote supposedly
ofSydenham was inInman's 1860 text was "Primum est ut
non nocere." However, the formwe know it in was a
misquote in a book review in 1860.

1. Smith CM.Origin anduses of primum non nocere--above
all, do no harm! J Clin Pharmacol.2005Apr;45(4):371-7.

 

Just as everyone seemed to agree EBM was importantand
thatwe just needed to clear up some details Sachin
Dave sent us an epistlefrom thereal world of 100%
clinical practice, saying that:

“I had deeplydrownedmyself in to EBM (teaching EBM) as
long as I was in an academicsetting. Lifechanged when
I joined a multi speciality group and a very
busypractice. As ayoung physician and a father of 10
yr. old and 8 yr. old life is hectic in private
practice. I find EBMloosely andwidely abused by many
including academically well placed techers
andpharmaceutical industry. I strongly feel the
following:

1. PracticingEBM in aprivate practice by 80-90% of the
physicians is practically impossible.Unfortunately the
reality is there is no reimbusement for the time
andeffort aphysician has to place in 'application' of
EBM.

2. As you seemore and morepatients and volume of
patient load increases, the "Art of Medicine"takes
precedence over the science. And practically speaking
the sciencemanytimes does not and will not replace the
'art of patient care'. 

Let a debatetake place asto how best can EBM be taken
form Ivory Towers of Academic Centers into the"heart"
of real life practice of EBM. Let a debate take place
as tohow the term EBM not be abused by sales
representatives, the respectedfacultymembers of
academic institutions and private practice paid
asconsultants toenhance what is exactly opposite of
EBM in name of EBM. Let a debatetake placeas to create
honest centers of excellence of EBM with total
integritywho cango and observe a busy practicing
physician and develop ways to let themintegrate EBM to
their extremely important art of medicine.”

This last paragraph was a rallying call to allthose
whovalue EBM but witness its non-use and misuse. Ben
Djulbegovic agreedwith thissaying:

“I am afraid heis right -EBM has been hijacked. No one
is against EBM (who can in the 21stcentury beagainst
evidence?). But what it is (and what isn’t) is
interpreted sodifferently by different parties that
EBM can be used as a kind ofRorschachtest to deduce
peoples’ understanding of the practice of medicine.”

 

What is agreed is that EBM is about getting
higherqualityresearch used in clinical practice, but
there are arguments about“quality” andmore divisively
about the process – the “how” to get evidence used.
Myown viewis that a higher proportion of practicing
clinicians need to be engagedincritically reading the
primary research. I don’t see that as a job wecan
leaveto others: others will not necessarily understand
the context and mayhaveother agendas such as making or
stopping profits. Rakesh Biswasexpressed theproblem
thus:

“EBM stands thedanger ofgetting increasingly divorced
from practical realities. One reason forthis maybe
because most physicians treat the evidence in journals
as blackboxes andjust gulp whatever is fed to them
(again is it often just because ofthe
timeconstraints?). What is needed is understandable
evidence that is notonly justdressed up fast food but
also tells us how the evidence
wascollected/synthesized in an "understandable real
world language".Most clinicians are skeptical of
evidence from studies because theykeepchanging so very
rapidly almost turning 180 degrees at times
thatsuggests thatmany of them were faulty or our
interpretations were faulty to startwith (allthat
observational beliefs getting swept away by RCTs etc)
. Howevercliniciansare helpless as they are unable to
interpret the evidence.”

 

That last statement is at the nub of the problem.We
are ina transition period where most current
clinicians are not highlyskilled in EBMbut where the
research flood continues to increase. Several
studieshave shownmost clinicians poor understanding of
essential concepts for readingpaperssuch as RRR, NNT
(and the other terms in our glossary), yet these
aretheequivalent of not understanding what red and
white blood cells are butbeingexpected to read a full
blood count. But most curricula spend more
timeonhemoglobin than on critical appraisal. However,
it is characteristic of“critical appraisal deficiency
syndrome” to be sure you don’t have it.RobMullen
illustrated this nicely with a recent survey:

“In 2005, weconducted aKnowledge-Attitudes-Practices
survey (n = about 600 Masters
levelspeechpathologists), and some of the findings
included: 12% were “verycomfortable”in their ability
to identify the study design in a journal article;
14%were“very comfortable” in their ability to assess
the quality of a journalarticle.Yes, even basic math
tells us that some folks feel their inability
toidentifythe study design doesn’t stand in their way
of assessing the quality ofastudy!   13% felt that
their “inabilityto interpret published research”
constituted a “major barrier” to theirabilityto engage
in evidence-based practice. One would have thought
that thisfigurewould have been closer to the 80%+ of
respondents who had difficultywith theprevious two
items. Instead, there seems to be the view
thatpeer-reviewedscientific evidence is somehow only
at the margins of evidence-basedpractice.I’d add more,
but suddenly am feeling very depressed and need to
liedown!”

 

I am reminded that it took the British Navy around50
yearsto adopt James Lind’s finding that citrus juice
could treat scurvy, andevenlonger for the practice to
be widespread. Meanwhile, if you areinterested
injoining in (or simply watching) the debate then you
can sign up for theEvidence-Based Health Care email
listserver at:

www.jiscmail.ac.uk/lists/EVIDENCE-BASED-HEALTH.html

 

Paul Glasziou for the Evidence-Based Health emaillist.



-- Paul GlasziouDirector, Centre for Evidence-Based
Medicine,Department of Primary Health Care,University
of Oxford www.cebm.netph +44-1865-227055 fax
+44-1865-227036



Bill Cayley, Jr, MD MDiv     [log in to unmask]

Augusta Family Medicine      Home Address
  207 W Lincoln                3433 McIvor St
  Augusta, WI  54722           Eau Claire, WI  54701
  Work:  715-286-2270          Home:  715-830-0932
  Page:  715-838-7940          Cell:  715-828-4636

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