What does evidence-based actually mean?
'Surely all medicine practiced today is evidence-based.'
or
'EBM just means blindly following guideline recommendations and trial results. It allows no place for professionalism, it is too rigid, and it does not "fit" the patient in front of me.'
Neither of these assumptions is true. The first one denies—against all evidence—that a problem exists, and the second is far from what the founders of EBM described.
Looking back to the publications on EBM from the early 1990s onwards gives a perspective of the serious issues they were tackling, and the desire to make this fun, as well as easy to understand and adopt. Rereading the original papers, it is disappointing to reflect on how little the paradigm has shifted.
Why? I would argue that adopting evidence-based practice (EBP) does not come easily to many. It requires us to be sceptical, to question our knowledge and beliefs, to identify the key questions, and to not be afraid to admit we don’t have all the answers.
There are facts in medicine in the science of anatomy, physiology, pharmacology, etc; however, medicine is often referred to as an art, and treatment choices are exactly that—a choice. Therefore, within medical practice, decisions are constantly being made. EBM is about making those decisions transparent and reducing bias as much as possible. Not just bias in study results, although this is an important area, but equally important is involving everyone in the decision: a multidisciplinary team which includes the patient, and their values and preferences, at its heart. By identifying where a decision is being made, acknowledging and communicating the choices involved and their implications, the best decision can be reached for and with an individual.
Which brings me to guidelines. It is concerning that, in trying to support an evidence-based approach, guidelines seem to be increasingly seen as directives and not what they set out to be—guidance. At the start of every NICE guideline you will find the following:
'The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.'
Is this caveat even read, let alone heeded to by the many who just skip to the summary of recommendations? Are doctors today so time-poor that their only option is to be spoon-fed information and blindly follow what they are told? I hope desperately that this isn’t the case.
So can EBM work in practice, and would it make any difference? One study found that regularly and systematically raising clinical questions through critically appraised topics (CATs) and best evidence topics (BETs), resulted in better patient outcomes compared to a traditional approach. A promising start to the evidence for the effectiveness of EBP.
The original EBM articles gave as much importance to evidence, as to the healthcare professional’s knowledge and experience, and the patient’s value and preferences—the intersection of this Venn diagram being EBM. Perhaps the focus has been too much on defining evidence, and EBM may have in certain circles become more of an academic pursuit. This was never the intention, and things are changing with a new focus in recent years on implementation, knowledge translation, and shared decision making. If the resulting new processes and tools are informative, without being overly prescriptive, then maybe there is a way in the future for all healthcare to be truly evidence-based.
Author: Caroline Blaine