Evidence-based medicine and the real world: understanding the controversy

Challenges and future directions in the measurement of evidence-based practice: Qualitative analysis of umbrella review findings

RATIONALE, AIMS AND OBJECTIVES: An important aspect of scholarly discussions about evidence-based practice (EBP) is how EBP is measured. Given the conceptual and empirical developments in the study of EBP over the last 3 decades, there is a need to better understand how to best measure EBP in educational and clinical contexts. The aim of this study was to identify and describe the main challenges, recommendations for practice, and areas of future research in the measurement of EBP across the health professions as reported by systematic reviews (SRs).

METHODS

We conducted a secondary analysis of qualitative data obtained in the context of a previously published umbrella review that aimed to compare SRs on EBP measures. Two reviewers independently extracted excerpts from the results and discussion/conclusion sections of the 10 included SRs that aligned with the three research aims. An iterative six-phase reflexive thematic analysis according to Braun and Clarke was conducted.

RESULTS

Our thematic analysis produced five themes describing the main challenges associated with measuring EBP, four themes outlining main recommendations for practice, and four themes representing areas of future research. Challenges include limited psychometric testing and validity evidence for existing EBP measures; limitations with the self-report format; lack of construct clarity of EBP measures; inability to capture the complexity of the EBP process and outcomes; and the context-specific nature of EBP measures. Reported recommendations for practice include acknowledging the multidimensionality of EBP; adapting EBP measures to the context and re-examining the validity argument; and considering the feasibility and acceptability of measures. Areas of future research included the development of comprehensive, multidimensional EBP measures and the need for expert consensus on the operationalization of EBP.

CONCLUSIONS

This study suggests that existing measures may be insufficient in capturing the multidimensional, contextual and dynamic nature of EBP. There is a need for a clear operationalization of EBP and an improved understanding and application of validity theory.

Does the current version of 'Tomorrow's Doctors' adequately support the role of evidence-based medicine in the undergraduate curriculum?

BACKGROUND

The evidence-based medicine (EBM) approach to clinical practice has been incorporated into medical training around the world. Whilst EBM is a component of the 'foundation years' (FY) programme, it appears to lack a firm foundation in the UK undergraduate curriculum.

AIM

To identify whether the teaching of EBM is adequately supported by the guideline 'Tomorrow's Doctors' (TD-2003).

METHODS

We mapped TD-2003 against the five steps of EBM and also reviewed the literature for reports concerning the introduction of EBM into undergraduate curricula.

RESULTS

Whilst all five steps of EBM can be mapped against TD-2003, the guidance makes no explicit reference to EBM and a coherent framework is lacking. The focus of undergraduate EBM teaching should be on 'using' research evidence (rather than undertaking research). The current emphasis on 'therapy' should be expanded to include the EBM-related issues of 'diagnosis, prognosis and harm'. UK medical schools also need to exploit the NHS investment in 'national electronic libraries'.

Taking stock of evidence-based medicine: opportunities for its continuing evolution

Tough but constructive criticisms of evidence-based medicine (EBM) have without doubt informed the evolution and serial reconstitutions of this approach to clinical decision making and behaviour. Yet, concerns about EBM persist and as EBM changes in response to reflection and criticism, so too do the criticisms themselves. This paper describes our current understanding of EBM and, to identify opportunities for the continuing evolution of EBM, discusses some key attributes of EBM that still or now cause us concern. Specifically, these attributes are the nature of evidence in EBM; the unknown effectiveness of EBM; the clinician-centric focus of EBM; and the potential of EBM to harm patients.

Evidence-based psychiatry: understanding the limitations of a method

Evidence-based psychiatry (EBP) is an important and useful method. However, it covers only a limited range of clinical problems psychiatrists and psychotherapists encounter in daily work. This is due to some particularities of psychiatric diagnoses and therapeutic practice. (i) The validity of psychiatric diagnoses is limited. EBP is entirely depending on diagnoses, so one of its core assumptions is of doubtful applicability in the field of psychiatry and psychotherapy. (ii) Effects of complexity are more obvious in psychiatric and psychotherapeutic cases. Owing to its conceptual bases, EBP cannot sufficiently consider such effects and is therefore of limited usefulness addressing particular problems in fluctuating or symptomatically shifting diseases. (iii) EBP's strong focusing on decision making does not reflect appropriately the clinical reality of psychiatrists and psychotherapists. Diagnostic and therapeutic procedures are in fact more iterative, and decisions are constantly re-evaluated. EBP is not helpful to adjust this type of individual approach, which is needed to treat individual patients.

A critical appraisal of evidence-based medicine: some ethical considerations

Evidence-based medicine (EBM) is a concept that has grown to dominate the medical literature over the last decade. EBM has provoked a variety of criticisms, scientific, philosophical and sociological. However, while its basic conclusion--that we should practise EBM--is ethical, there has been limited ethical analysis of EBM. This paper aims to provide an analysis of EBM from an ethical perspective and identify some of EBM's potential ethical implications. Following a description of what constitutes EBM, this paper will identify and assess some of the basic values and epistemological assumptions of EBM that provide support for the moral duty to practise EBM. It will then examine potential ethical implications that could arise from practising EBM, given the challenges that have been made of EBM's assumptions and claims to authority. This paper will conclude by arguing that practitioners could strengthen the ethics of EBM by embracing a broader definition of evidence and including ethical criteria in the critical appraisal of research studies.

Reluctant empiricists: community mental health nurses and the art of evidence-based praxis

The National Service Framework for Mental Health (1999) emphasizes the need for a culture of evidence-based practice (EBP) in mental health care. However, there is relatively little research addressing EBP from the perspective of community mental health nurses and we are still unsure of why the uptake of this style of working has been slow. This paper suggests that rather than thinking in terms of 'barriers' to the uptake of EBP, the issue may best be conceptualized as a form of praxis on the part of nurses, as they seek to manage the diversity of ideologies and practices in their working lives. From an interview and focus group study, we identify how practitioners' narrow definition of EBP itself, their formulation of how EBP was at odds with the nurse's professional activity and the organizational constraints within which they work were perceived to inhibit access to information and offer little time and managerial support for information seeking. Those who attempt to further the involvement of community mental health staff in EBP will have to reconceptualize the reasons why staff have yet to incorporate it fully, and acknowledge that this does not occur because staff are simply 'ignorant Luddites', but that this resistance enables them to retain a sense of control over their working lives and retain a focus on work with clients. Future EBP initiatives will have to address these ideological and organizational factors in order for uptake to be accelerated. This may involve changing organizational cultures and work roles and even encouraging activism on the part of the practitioners so as to enable them to learn from each other and educate and change their work environments.

Beyond evidence-based medicine: bridge-building a medicine of meaning

Contesting that a debate on evidence-based health care has taken place, this article charts three paths to the future: continuing avoidance of debate by proponents of evidence-based medicine (EBM); conflict, which the EBM movement courts and critics have espoused, and dialogue. The last portal allows for integration, which would end the disagreement between EBM and its critics and make a debate unnecessary. In search of integration, I sketch a bridge whose construction requires not compromise but a win- win approach. The bridge is a medicine of meaning (MOM). Consolidating multiple pillars of evidence to unify questions that are not necessarily the same for protagonists and critics of EBM, a MOM contends that the purpose or meaning of medicine is always healing and helping, and each party finds meaning in medicine by contributing to this common purpose in its own distinctive way.