Twenty years of evidence based medicine: a reappraisal

Symbol of the Cochrane Collaboration, a major evidence based resource provider.

A recent paper, written by Trisha Greenhalgh and other members of the Evidence Based Medicine Renaissance Group on this subject was published in June's BMJ. The concept of evidence based medicine underpins all the training and teaching at our library which was why we selected this paper to discuss at our librarians' journals club this month.

Greenhalgh, known to all medical librarians, and probably most UK trainee medical and nursing students for her book How to read a paper explains that more than 20 years ago the evidence based working group published a paper in JAMA announcing “a ‘new paradigm’ for teaching and practicing clinical medicine: tradition, anecdote and theoretical reasoning from basic sciences would be replaced by evidence from high quality randomised controlled trials and observational studies, in combination with clinical expertise and the needs and wishes of patients”. Twenty years later the paper examines the way the concept has been developed and used, often very effectively. Practices still vary across regions with some advice being ignored. The issues involved are very interesting: how much variation from the guidelines should be tolerated: what is the relationship between rule following, learning and judgement and how usable are guidelines in practice?

As ever, the drugs and pharmaceutical industry seem to be manipulating agendas and measurements to suit their own ends; redefining conditions such as baldness and female sexual arousal disorder and low bone density as suitable subjects for clinical medication, not publishing unfavourable results and exercising undue influence over politicians.

To some extent evidence based medicine has been a victim of its own success, with thousands of new guidelines being developed:  a 2005 audit of a 24hr medical take in in an acute hospital included 18 patients with 44 diagnoses and identified 3679 pages of national guidelines (an estimated 122 hours of reading) relevent to their immediate care.

Perhaps the pendulum has now swung too far, for the team argue that there has been too much emphasis on following rules. Use of computerised decision support systems, structured templates and point of care prompts can crowd out the local, individualised and patient initiated elements of the clinical consultation. They stress the need for listening and shared decision making. Worse still, evidence based medicine has led to the Quality and Outcomes Framework, which they term ‘an audit driven, technocratic exercise’ now implemented by non-clinical managers who can manipulate the statistics for instance recalling patients for structured reviews and checks to generate ‘quality points’.

Instead they argue:
"Real evidence based medicine:

•  Makes the ethical care of the patient its top priority
• Demands individualised evidence in a format that clicicians and patients can understand
• Is characterised by expert judgement rather than mechnanical rule following
• Shares decisions with patients through meanignful conversations
• Builds on a strong clinican-patient relationship and the human aspects of care
• Applies these principles at community level for evidence based public health."

They recommend changes in training , support tools, publishing practices, research agendas  and policies to support these changes.
I thought this article was easily the most interesting work related article I had read for several years (having suggested it myself was a bonus of course!)

At our journals club we considered the implications for this paper for three groups: doctors, patients and librarians. We thought about campaigns by Sir Iain Chalmers' and others to rationalise the research agenda through organisations like DUETS, and how the term 'evidence based medicine' first championed partly by David Sackett has evolved into 'evidence based healthcare' 'evidence based librarianship' and beyond to 'evidence based practice'. We discussed the varying success of attempts to embed information skills into medical training curriculums. We considered how clinical librarians (librarians attached to hospital departments)  often had success in pilot schemes, but that the wide range of departments meant that the cost implications of scaling up the pilot schemes often meant that these schemes were not adopted on a larger scale despite their success. We also learned some new terms such as: polypharmacy and several others that I am to embarassed to admitting to not knowing before.

see
Greenhalgh, T. Howick J. and Maskrey, N. Evidence based medicine: a movement in crisis? BMJ; 2014 Jun 13;348:g3725. doi: 10.1136/bmj.g3725. http://www.bmj.com/content/348/bmj.g3725
Evidence Based Working Group, Evidence based medicine: a new approach to teaching the practice of medicine. JAMA 1992; 268: 2420-5