This appeared last week:
Essay
Evidence based medicine: a movement in crisis?
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g3725 (Published 13 June 2014)
Cite this as: BMJ 2014;348:g3725
- Trisha Greenhalgh, dean for research impact1,
- Jeremy Howick, senior research fellow2,
- Neal Maskrey, professor of evidence informed decision making3
- for the Evidence Based Medicine Renaissance Group
Author Affiliations
- Correspondence to: T Greenhalgh p.greenhalgh@qmul.ac.uk
Trisha Greenhalgh and colleagues argue that, although evidence based medicine has had many benefits, it has also had some negative unintended consequences. They offer a preliminary agenda for the movement’s renaissance, refocusing on providing useable evidence that can be combined with context and professional expertise so that individual patients get optimal treatment
It is more than 20 years since the evidence based medicine working group announced a “new paradigm” for teaching and practising clinical medicine.1 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.
Evidence based medicine quickly became an energetic intellectual community committed to making clinical practice more scientific and empirically grounded and thereby achieving safer, more consistent, and more cost effective care.2 Achievements included establishing the Cochrane Collaboration to collate and summarise evidence from clinical trials;3 setting methodological and publication standards for primary and secondary research;4 building national and international infrastructures for developing and updating clinical practice guidelines;5 developing resources and courses for teaching critical appraisal;6 and building the knowledge base for implementation and knowledge translation.7
From the outset, critics were concerned that the emphasis on experimental evidence could devalue basic sciences and the tacit knowledge that accumulates with clinical experience; they also questioned whether findings from average results in clinical studies could inform decisions about real patients, who seldom fit the textbook description of disease and differ from those included in research trials.8 But others argued that evidence based medicine, if practised knowledgably and compassionately, could accommodate basic scientific principles, the subtleties of clinical judgment, and the patient’s clinical and personal idiosyncrasies.1
Two decades of enthusiasm and funding have produced numerous successes for evidence based medicine. An early example was the British Thoracic Society’s 1990 asthma guidelines, developed through consensus but based on a combination of randomised trials and observational studies.9 Subsequently, the use of personal care plans and step wise prescription of inhaled steroids for asthma increased,10 and morbidity and mortality fell.11 More recently, uptake of the UK National Institute for Health and Care Excellence guidelines for prevention of venous thromboembolism after surgery has produced significant reductions in thromboembolic complications.12
Despite these and many other successes, wide variation in implementing evidence based practice remains a problem. For example, the incidence of arthroscopic washout of the knee joint, whose benefits are unproved except when there is a known loose body, varies from 3 to 48 per 100 000 in England.13 More fundamentally, many who support evidence based medicine in principle have argued that the movement is now facing a serious crisis (box 1).14 15 Below we set out the problems and suggest some solutions.
Box 1: Crisis in evidence based medicine?
· The evidence based “quality mark” has been misappropriated by vested interests
· The volume of evidence, especially clinical guidelines, has become unmanageable
· Statistically significant benefits may be marginal in clinical practice
· Inflexible rules and technology driven prompts may produce care that is management driven rather than patient centred
· Evidence based guidelines often map poorly to complex multimorbidity
The further many pages and references are found here:
The rapid responses to the article are also excellent reading including a less useful one from yours truly.
Re: Evidence based medicine: a movement in crisis?
22 June 2014
This is just fantastic stuff but somehow seems to beg the question of just where the trustworthy, easily assimilated and person / patient centric information can be consistently sourced.
I think we all have a pretty clear idea of the problem - it is how we now set out to manage it that worries me.
I would love to know the answer to this, as well as to understand how we can shorten the time gap between established clinical practice and large scale clinical understanding and adoption.
My sense is that complexity is one of the issues we really have to address.
Dr David G More MB, PhD, FANZCA, FCICM.
I suggest those who are interested can happily spend a good hour or two learning a great deal and coming to understand just how far we have to go in all this. The relevance of all this to electronic clinical decision support cannot be overstated!
David.
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