Dear all,

I find this thread fascinating but I'd like to pick up on one of the
areas in particular.  I am a Clinical Lecturer in Paediatric Dentistry
in the UK and worked in general practice for a number of years (so have
a fair idea about application in the "real world").  From a cultural
perspective, I feel that evidence based dentistry is, in many ways,
streets behind EBM but I wonder if any face lift we might be considering
might seek to widen the horizons of EBM and instead of referring to
medicine perhaps someone can come up with a more imaginative title
"evidence based healthcare", "evidence based practice", "evidence
focused care" - I don't know, there are greater minds than mine on this
list.
Why do I think this should be considered?
Firstly, There are so many disciplines both allied to medicine
(physiotherapy, speech and language therapy, pharmacy etc etc) who are
involved in (or evolving) evidence orientated care that we could make
use of the opportunity to encourage our broadening perceptions of health
as well as reducing barriers to the perceived relevance of evidence to
practitioners outside of medicine.
My second reason is more from a clinical reason and possible just a
personification of the above.  We have a huge gulf in what we perceive
as health in the body and what we perceive as health in the oral
environment.  Dental care is amongst the greatest unmet health need of
children and yet we persist in separating (mainly for historical and
paymaster reasons) the body from the mouth.  i.e. it's OK to have an
abscess in your child's mouth that gives them pain (and maybe not even
seek treatment) but it wouldn't be considered acceptable on any other
part of their body.  Wendy Mouradian speaks far more eloquently on this
than I do.  Dental/ oral and other health and social needs are closely
tied in but remain separated in our minds. It would be helpful if we
could use evidence based delivery of healthcare to reduce this gap. 
Lastly, my teaching environment is not steeped in an evidence based
orientation and I have difficulty persuading my dental students and the
general practitioners that I teach that evidence base isn't just for
making sure you get the most appropriate treatment for your cancer or MI
but has to apply to every encounter we have with a patient and every
decision we assist them to make.  Maybe it's not only dentistry that is
reluctant to adopt an evidence based culture.
Nicola Innes
Clinical Lecturer in Paediatric Dentistry
University of Dundee,
UK






Dear all,

As a practitioner and teacher of EBM I always had the feeling that EBM
needs a face-lift.

First the name itself needs to be taken a step forward to be
Evidence-Based Medical Practice (EBMP)rather than Evidence Based
Medicine. This will give it the needed feel of being an approach for
medical practice rather than an "academic science" for research and
researchers.

Second, it is evident to every one that EBM is not widely practiced by
physicians as we all wish for it. This is mainly because we ask
physicians to do many exhausting steps if they face a clinical problem
and forget about the difficulties that they usually encounter that can
be summarized in the following:
1. The lack of access to resources as most resources require a
subscription and this is particularly important for the poor developing
countries.
2. The lack of pre-appraised evidence in many areas in medicine.
3. The lack of knowledge about critical appraisal by many physicians.
4. Even knowledgeable physicians have difficulties in searching the
literature to get a set of researches that is as complete as possible to
appraise.
5. The lack of time needed for critical appraisal of a set of papers
addressing a specific PICO question taking into consideration that a
Cochrane systematic review takes not less than 1 year to be finished!
6. The lack of resources as some interventions and diagnostic
modalities  might not be available to physicians in certain areas of the
country and EBM does not address the alternatives. For a simple example,
spirometers for diagnosing bronchial asthma in children. What should
physicians do if the evidence is not available to them?
7. Variation in patient's values and preferences.

Third, It is supposed that EBM has been developed to avoid
controversies in medical practice and to "filter" the irrelevant
literature and to "summarize" the enormously increasing relevant
literature. However, EBM is walking through the same road once again as
EBM web sites and resources are enormously increasing leaving users in
the same dilemma they faced before and I still remember our conversation
in the list (of professionals) about the best 6 databases to recommend
that ended up with more than 30 databases!

To cut it short, as it is already long enough, we should direct our
forces to ways that make it easier to practitioners to find the evidence
if we want them to follow it? 
Would this be by issuing evidence-based clinical guidelines or
management protocols for every disorder? And perhaps asking health
authorities/syndicates/societies to force these guidelines/protocols on
practitioners in every discipline or country?
Or perhaps we still need to better explore the needs and expectations
of practitioners and their opinions about how to make things easier to
them?

Sorry for a long email.

Abdelhamid Attia
Prof. Dr. Abdelhamid Attia
Prof. of Ob & Gyn, Cairo University
President; Arab Federation of EBM