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I am out on vacation and return on 8-27-06. Sincerely, Sachin Dave, MD. Indianapolis, IN AnjanaN Patel <[log in to unmask]> wrote:Re: Why is EBM Important? Dear All, I have been following this debate with great interest and would like to offer a viewpoint from a different perspective. My viewpoint is from the perspective of a British pharmacist who has been involved in promoting rational prescribingı for around 20 years. There is a lot of overlap between what British pharmacists used to refer to as rational prescribingı and what is currently being debated under the heading of Evidence based medicine. I would endorse what others have already said about the usfulness of this article for a wider readership. However, my suggestion is that it would be useful to include a definition of WHAT IS EBM? before discussing WHY IS EBM IMPORTANT? - the questions of WHO, WHEN and HOW would then follow on naturally. I have personally found the following to be a useful way of looking at the WHAT and HOW of evidence-based/rational prescribing. Taking the texbook definition of Evidence Based Medicine as a starting point EBM = clinical expertise [skill required for applying the evidence in clinical practice] + patient values [using the artı skills of medicine to involve the patient in the decision making process] + best research evidence [the science of medicine where the systematic assessment of information contributes to medical knowledge]. Clinical expertise, patient values and best research evidence are inter-related. Just as research evidence informs clinical practice, clinical expertise and patient values inform the research agenda 1. Clinical expertise and patient values. Best evidence is about establishing the level of uncertainty associated with a particular intervention for all known outcomes (both beneficial and harmful) Clinical expertise and patient values are intrinsically linked and therefore before looking for best evidenceı about effects and making decisions about effectiveness it is necessary to decide an order of priority of importance to the patient of the known possible outcomes of an intervention (both beneficial and harmful). The priority and acceptabilty of all known possible outcomes needs to be established. Only then can the possible benefits and risks of a particular intervention for that particular patient can be discussed. It is also important to convey the level of uncertainty about achieving the most important outcomes (for the patient). 2. Best research evidence (both primary and secondary research). Evidence-based - that [which] is based on some sort of systematic assessment of evidence. Evidence - ANY observation about nature of the world Quality of evidence in terms of both relevance (is the right question being asked?) and validity (Is the study design appropriate to answer the particular question being asked?). It is necessary to first ask the question Is the study design appropriate for the question being askedı before deciding whether or not a randomised controlled trial would be the best way to answer the question. Outcomes: Are the outcomes being measured relevant for both clinicians and patients? As it needs a finite amount of time to properly assess the quality in terms of validity of research findings, in a clinical setting it is useful to first answer the question Is a particular piece of research (primary or secondary) RELEVANT in terms of both the QUESTION of interest in and the OUTCOMES that are important to patients. Anjana on 10/8/06 11:05 am, Paul Glasziou at [log in to unmask] wrote: Dear All, I thought the recent discussion on Why EBM raised many excellent points: it was so good I thought we should publish a digest of this in the EBM Journal. So can I ask the list members (and particularly the quoted folk - Bill Cayley, Amit Ghosh, Neil Maskrey, Stephen Perle, Sachin Dave, Ben Djulbegovic, Rakesh Biswas and Rob Mullen) to look at the article and get any feedback to me by next Monday at the latest? Thanks for all the contributions. Paul Glasziou ------ Why is EBM important? Iım sure readers of the Evidence-Based Medicine journal have a variety of reasons for subscribing. But most of you would assume EBM is important to clinicians. Recently Olive Goddard (the manager at the CEBM in Oxford) forwarded this question to the Evidence-Based Health Care list: "Could you please tell me why EBM is important? Can a physician practice medicine without knowing EBM?" The email list has over a thousand subscribers and many had an opinion about this question. I will abbreviate these to highlight some of the threads, but you can read the full text on the list. Bill Cayley kicked us off by saying that: ³Hereıs my answer along the lines of the introduction I give our medical students: In medicine, we are continually making decisions, and if medicine is to be a science or a ³learned² profession, we need to think critically about HOW and WHY we make those decisions. There are a number of potential approaches to making decisions: 1) Tradition (³weıve always done it this way², ³my teachers did it this way²); 2) Convention (³everyone else always does it this way² ie, going with the crowd), 3) Belief or Dogma (³I believe the natural way is best²), 4) ³Evidence-based² that is based on some sort of systematic assessment of evidence. Further, I discuss with my students the fact that you can look at evidence as simply ANY observation about the nature of the world. In the medical literature, we call a single, isolated instance of something an ³anecdote² (or, if published, a ³case report²). If you take a bunch of observations and group them together, we have a ³case series². You can go on up from there in terms of the rigor, systematization, and thoroughness of evidence evaluation up to the double-blinded randomized trial or the meta-analysis. ALL observations can be considered ³evidence² itıs just a matter of asking what the QUALITY of your evidence is.² A great start to the discussion. The textbook definition (roughly) says that EBM = clinical expertise + patient values + best research evidence. That last element is tricky and requires search skills, resources, and the critical examination suggested by Cayley. Of course, patients are always surprised that clinicians are not already using ³the best research evidence². So why doesnıt that happen? Well Amit Ghosh chimed in and added that: ³until Sackett and Guyatt's introduction of the discipline of EBM I am not sure if we did look into studies as critically as we do now. The medical curriculum was deficient in this aspect and even now in many places only catching up. The bigger question that remains is whether teaching the basics of EBM would be an answer to all the problems when the physician has little control on anything else. The over simplistic way to think is that critically reviewing an article would provide the best evidence for the patient (we don't make that promise any more). The issues surrounding successful implementation of EBM in medical schools are far more complicated with mega secondary sources of information like UpToDate and others coming to the physicians rescue more frequently than the complicated juggernaut of negotiating Brian Haynesı 4S model (Systems, Synthesis, Secondary sources, and Studies). In all fairness despite it great precision and depth, Cochrane reviews are hard to digest in the time that any practitioner will ever have (average review is 50 pages). The final blame always falls in our inability to fulfill the promise that many of us make that teaching EBM will it solve most the problems. In all its simplicity and complexity EBM has unraveled a whole set of issues confronting medical education and medical practice and we thank the McMaster Group for this step forward. How we finally use EBM in an uniform fashion, all around the globe remains the experiment for the near future. So EBM is important, but its practice needs to evolve. There are still critical barriers in our evidence resources and deficiencies in many medical curricula. As Bill Cayley later added ³... some perceived the promise that EBM would answer all our problems (if that promise was ever there) was overstated. It's one thing to know we need evidence, it's entirely different to a) FIND the evidence, and b) APPLY it.² So how and where does EBM fit in with current important elements of the medical curriculum? It can be seen as an overlap between research (often covered in statistics) and decision making (often covered in ethics). Someone once suggested the key ethical decision making principles are expressed by the French Revolution motto of Liberte (autonomy), Egalite (Equity or justice), and Fraternity (Benevolence). Neal Maskrey considered how EBM fits this framework when he suggested: ³We ask people to first describe their ethical framework for decision making. Hopefully we get to something like this: (i) First do no harm (Safety) - well done Hippocrates, but what next? (ii) Try and do good - efficacy and effectiveness, (iii) Justice / Equity - most health care practitioners and especially students have an inner drive for fairness, and it's entirely legitimate therefore to consider benefits:cost from a population as well as individual perspective, (iv) Patient autonomy (it's called assaulting patients if you don't ask the patient and respect their wishes). So what sort of evidence would you expect people to use to populate these four ethical domains and then weight them up when decision making? Obviously we could just do what others told us or what we've always done or what we intuitively believe. But PATIENTS Have the right to expect us to use the best evidence that's available to help them. We are here to serve our patients and we therefore need to strive to avoid falling into the traps of the cognitive biases e.g. of believing what we see, or have done before and think works, or what others tell us, or indeed of basing our practice on pathophysiological mechanisms where better evidence exists. What approaches can be used to make decisions (weigh up the values of the four domains)? This is in my experience best debated over a very good dinner (with a decent bottle of wine for those who wish!). So EBM is important as a critical element of medical decision making and medical ethics. Given most treatments have some harm, or at least an opportunity cost, an initial concern of EBM has been to avoid using ineffective interventions and hence follows the dictum of firstly do no harm. However, Stephen Perle reminded us of the different flavours of "evidence" include historical attributions by pointing out that: ³primum non nocere was first in the English literature in 1860, with attribution to the English physician, Thomas Sydenham (1624-1689). The quote supposedly of Sydenham was in Inman's 1860 text was "Primum est ut non nocere." However, the form we know it in was a misquote in a book review in 1860. 1. Smith CM. Origin and uses of primum non nocere--above all, do no harm! J Clin Pharmacol. 2005 Apr;45(4):371-7. Just as everyone seemed to agree EBM was important and that we just needed to clear up some details Sachin Dave sent us an epistle from the real world of 100% clinical practice, saying that: ³I had deeply drowned myself in to EBM (teaching EBM) as long as I was in an academic setting. Life changed when I joined a multi speciality group and a very busy practice. As a young physician and a father of 10 yr. old and 8 yr. old life is hectic in private practice. I find EBM loosely and widely abused by many including academically well placed techers and pharmaceutical industry. I strongly feel the following: 1. Practicing EBM in a private practice by 80-90% of the physicians is practically impossible. Unfortunately the reality is there is no reimbusement for the time and effort a physician has to place in 'application' of EBM. 2. As you see more and more patients and volume of patient load increases, the "Art of Medicine" takes precedence over the science. And practically speaking the science many times does not and will not replace the 'art of patient care'. Let a debate take place as to how best can EBM be taken form Ivory Towers of Academic Centers in to the "heart" of real life practice of EBM. Let a debate take place as to how the term EBM not be abused by sales representatives, the respected faculty members of academic institutions and private practice paid as consultants to enhance what is exactly opposite of EBM in name of EBM. Let a debate take place as to create honest centers of excellence of EBM with total integrity who can go and observe a busy practicing physician and develop ways to let them integrate EBM to their extremely important art of medicine.² This last paragraph was a rallying call to all those who value EBM but witness its non-use and misuse. Ben Djulbegovic agreed with this saying: ³I am afraid he is right - EBM has been hijacked. No one is against EBM (who can in the 21st century be against evidence?). But what it is (and what isnıt) is interpreted so differently by different parties that EBM can be used as a kind of Rorschach test to deduce peoplesı understanding of the practice of medicine.² What is agreed is that EBM is about getting higher quality research used in clinical practice, but there are arguments about ³quality² and more divisively about the process the ³how² to get evidence used. My own view is that a higher proportion of practicing clinicians need to be engaged in critically reading the primary research. I donıt see that as a job we can leave to others: others will not necessarily understand the context and may have other agendas such as making or stopping profits. Rakesh Biswas expressed the problem thus: ³EBM stands the danger of getting increasingly divorced from practical realities. One reason for this may be because most physicians treat the evidence in journals as black boxes and just gulp whatever is fed to them (again is it often just because of the time constraints?). What is needed is understandable evidence that is not only just dressed up fast food but also tells us how the evidence was collected/synthesized in an "understandable real world language". Most clinicians are skeptical of evidence from studies because they keep changing so very rapidly almost turning 180 degrees at times that suggests that many of them were faulty or our interpretations were faulty to start with (all that observational beliefs getting swept away by RCTs etc) . However clinicians are helpless as they are unable to interpret the evidence.² That last statement is at the nub of the problem. We are in a transition period where most current clinicians are not highly skilled in EBM but where the research flood continues to increase. Several studies have shown most clinicians poor understanding of essential concepts for reading papers such as RRR, NNT (and the other terms in our glossary), yet these are the equivalent of not understanding what red and white blood cells are but being expected to read a full blood count. But most curricula spend more time on hemoglobin than on critical appraisal. However, it is characteristic of ³critical appraisal deficiency syndrome² to be sure you donıt have it. Rob Mullen illustrated this nicely with a recent survey: ³In 2005, we conducted a Knowledge-Attitudes-Practices survey (n = about 600 Masters level speech pathologists), and some of the findings included: 12% were ³very comfortable² in their ability to identify the study design in a journal article; 14% were ³very comfortable² in their ability to assess the quality of a journal article. Yes, even basic math tells us that some folks feel their inability to identify the study design doesnıt stand in their way of assessing the quality of a study! 13% felt that their ³inability to interpret published research² constituted a ³major barrier² to their ability to engage in evidence-based practice. One would have thought that this figure would have been closer to the 80%+ of respondents who had difficulty with the previous two items. Instead, there seems to be the view that peer-reviewed scientific evidence is somehow only at the margins of evidence-based practice. Iıd add more, but suddenly am feeling very depressed and need to lie down!² I am reminded that it took the British Navy around 50 years to adopt James Lindıs finding that citrus juice could treat scurvy, and even longer for the practice to be widespread. Meanwhile, if you are interested in joining in (or simply watching) the debate then you can sign up for the Evidence-Based Health Care email listserver at: www.jiscmail.ac.uk/lists/EVIDENCE-BASED-HEALTH.html <http://www.jiscmail.ac.uk/lists/EVIDENCE-BASED-HEALTH.html> Paul Glasziou for the Evidence-Based Health email list. --------------------------------- Stay in the know. Pulse on the new Yahoo.com. Check it out.