Continuing the evidence-based health care debate in 2006. The progress and price of EBM

Evidence, discovery and justification: the case of evidence-based medicine

The purpose of this paper is to develop some thoughts on philosophical issues surrounding evidence-based medicine (EBM), especially related to its epistemological dimensions. After considering the scope of several philosophical concepts that are relevant to the discussion, and drawing some distinctions among different aspects of EBM, we evaluate the status of EBM and suggest that EBM is mainly a meta-methodology. Then, we outline an evaluation of the thesis that EBM is a 'new paradigm' in the practice of medicine. We argue that EBM does not seem to have arisen in the way Kuhn imagined paradigms to arise but as a conscious, deliberate proposal, more as programme than as a reality. Furthermore, there is something paradoxical about appealing to evidence or to the best evidence as a way of promoting a new paradigm. For the proposal seems to assume that there is something that by its own virtue is the best evidence for a given time. But this idea would have been rejected by Kuhn. If EBM involves a genuine new alternative in the field of medicine and shows a way in which the discipline will endure henceforth, this indicates that it is not what Kuhn once called a 'paradigm' and even, paradoxically, it is good evidence that scientific paradigms do not exist, at least in medicine.

Evidence-based medicine: is it a bridge too far?

AIMS

This paper aims to describe the contextual factors that gave rise to evidence-based medicine (EBM), as well as its controversies and limitations in the current health context. Our analysis utilizes two frameworks: (1) a complex adaptive view of health that sees both health and healthcare as non-linear phenomena emerging from their different components; and (2) the unified approach to the philosophy of science that provides a new background for understanding the differences between the phases of discovery, corroboration, and implementation in science.

RESULTS

The need for standardization, the development of clinical epidemiology, concerns about the economic sustainability of health systems and increasing numbers of clinical trials, together with the increase in the computer's ability to handle large amounts of data, have paved the way for the development of the EBM movement. It was quickly adopted on the basis of authoritative knowledge rather than evidence of its own capacity to improve the efficiency and equity of health systems. The main problem with the EBM approach is the restricted and simplistic approach to scientific knowledge, which prioritizes internal validity as the major quality of the studies to be included in clinical guidelines. As a corollary, the preferred method for generating evidence is the explanatory randomized controlled trial. This method can be useful in the phase of discovery but is inadequate in the field of implementation, which needs to incorporate additional information including expert knowledge, patients' values and the context.

CONCLUSION

EBM needs to move forward and perceive health and healthcare as a complex interaction, i.e. an interconnected, non-linear phenomenon that may be better analysed using a variety of complexity science techniques.

Medical students' attitudes on and experiences with evidence-based medicine: a qualitative study

RATIONALE, AIMS AND OBJECTIVES

This qualitative study was designed to determine the attitudes towards and experiences of medical students on evidence-based medicine (EBM).

METHODS

The study was conducted using the phenomenological method. Medical students' attitudes about and experiences with evidence-based medicine were determined through semi-structured interviews. Forty senior medical students were chosen by purposive sampling from medical sciences students of Tabriz University and Shahid Beheshti University. The context of interviews was analysed using the content analysis method.

RESULTS

Medical students' attitudes and experiences were ascertained through four main questions, and their answers were divided in to 12 categories and 31 subcategories. According to the subjects of the study, two basic concepts that they understood about EBM were its being up to date and requiring research skills. To the question what is necessary for EBM, the students' answers were summarized as follows: access to information, teamwork and faculty members who could provide modeling and organizational support. Students reported having used EBM for problem solving, thinking and self-confidence. On the other hand, lack of equipment and facilities, human factors and organizational factors were considered the main barriers to EBM use.

CONCLUSION

According to the results of this study, providing suitable conditions and appropriate planning to address identified barriers and encouraging students can promote EBM practice. Also, more extensive EBM integration in medical curricula and clinical settings by leading faculty members would prompt medical students to use EBM in their daily practice.

Evidence-informed person-centred health care (part II): are 'cognitive biases plus' underlying the EBM paradigm responsible for undermining the quality of evidence?

INTRODUCTION

Recently, some leaders of the evidence-based medicine (EBM) movement drew attention to the "unintended" negative consequences associated with EBM. The term 'cognitive biases plus' was introduced in part I to encompass cognitive biases, conflicts of interests, fallacies and certain behaviours.

HYPOTHESIS

'Cognitive biases plus' in those closely involved in creating and promoting the EBM paradigm are responsible for their (1) inability to anticipate and then recognize flaws in the tenets of EBM; (2) discounting alternative views; and (3) delaying reform.

METHODS

A narrative review style was used, with methods as in part I.

APPRAISAL OF LITERATURE

Over the past two decades there has been mounting qualitative and quantitative methodological evidence to suggest that the faith placed in (1) the EBM hierarchy with randomized controlled trials and systematic reviews at the summit; (2) the reliability of biostatistical methods to quantitate data; and (3) the primacy of sources of pre-appraised evidence, is seriously misplaced. Consequently, the evidence that informs person-centred care is compromised.

DISCUSSION

Arguments focusing on 'cognitive biases plus' are offered to support our hypothesis. To the best of our knowledge, EBM proponents have not provided an explanation.

CONCLUSIONS

Reform is urgently needed to minimize continuing risks to patients. If our hypothesis is correct, then in addition to the suggestions made in part I, deficiencies in the paradigm must be corrected. Meaningful solutions are only possible if the biases of scientific inbreeding and groupthink are minimized by collaboration between EBM leaders and those who have been sounding warning bells.

Making the improbable probable: communication across models of medical practice

Cooperation and conversation in the public sphere may overcome historical and other barriers to rational argumentation. As an alternative to evidence-based medicine (EBM) and patient-centered care (PCC), the recent development of a modern version of person-centered medicine (PCM) signals an opportunity for a conversational pluralogue to replace parallel monologues between EBM and its critics, and the calls to EBM to debate its critics. This article draws upon elements of Habermas's theory of communicative action in order to suggest the kind of pluralogue that is required for stakeholders in modern medicine to benefit more from publicly conversing with each other than speaking alone or using debate to argue against each other. This reasoned perspective has lessons for all discourse when deep value-based and epistemological differences cannot be easily adjudicated.

Evidence-based practice: SLTs under siege or opportunity for growth? The use and nature of research evidence in the profession

BACKGROUND

Speech and language therapists are encouraged to be evidence-based practitioners in contemporary clinical practice. This apparently signifies their commitment to 'good' practice. An examination of evidence-based practice (EBP) and its adoption in clinical practice is therefore warranted.

AIMS

This paper aims to explore EBP, specifically research evidence, as related to the field of speech and language therapy (SLT), using profession specific and cross-disciplinary examples. It asks the reader to consider whether research evidence contributes positively to SLT practice, or adds to the demands placed on clinicians?

METHODS & PROCEDURES

A review of the literature on the nature and use of research evidence in the field of speech and language therapy and related health professions was undertaken using multiple databases (Cochrane, Medline, Cinahal, BioMed, Trip, Dare) and the following up of references provided within texts and articles. This paper asks the reader to consider the topic from the perspective of the nature of research produced, the barriers perceived, and the use of research evidence by SLTs and the allied health professions.

OUTCOMES & RESULTS

The uptake of research evidence in the profession is similar to other health professions and continues to be problematic. There are multiple reasons why this is so, originating from both the nature and use of research.

CONCLUSIONS & IMPLICATIONS

Research evidence is one of the pillars of EBP. Despite problems with the nature and use of such evidence, it has a positive contribution to make to clinical practice as it provides for a scientific touchstone. However, it may be that the speech and language therapist and not the research evidence is the primary pivot upon which scientific practice is based.

["Evidence-based medicine" and "mixed methods": how methodological discussions in the medical and social sciences could benefit from each other]

The debate about adequate research methods for obtaining relevant results in clinical medicine and health care does not take place in a vacuum. In the present paper the longstanding debate about the epistemological underpinnings and methodological perspectives of qualitative and quantitative research methods in the social sciences is outlined and fructified for evidence-based medicine and health care. By using examples from research practice we will demonstrate that both the utilisation of qualitative methods and the use of a "mixed methods" design may contribute to the current methodological debate and improve research practice in evidence-based health care.

Harnessing experience: exploring the gap between evidence-based medicine and clinical practice

RATIONALE, AIMS AND OBJECTIVES

There is mounting evidence of a gap between Evidence-based Medicine (EBM) and physician clinical practice, in part because EBM is averaged global evidence gathered from exogenous populations which may not be relevant to local circumstances. Local endogenous evidence, collected in particular and 'real world' patient populations may be more relevant, convincing and timely for clinical practice. Evidence Farming (EF) is a concept to provide such local evidence through the systematic collection of clinical experience to guide more effective practice.

METHODS

We report on the findings of a pilot study of 29 individual and three focus group (n = 10) interviews exploring physicians' evaluations how they use multiple sources of information in clinical decision making and their thoughts on EF.

RESULTS

Physicians recognize a gap in translating EBM to practice. Physicians reported that when making clinical decisions, they more often rely on clinical experience, the opinions of colleagues and EBM summarizing electronic clinical resources rather than refer directly to EBM literature. Confidence in making decisions based on clinical experience increases over time, yet few physicians reported having systems for tracking their clinical experience in designing treatment plans and patient outcomes. Most physicians saw EF as a promising way to track experience, thereby making scientific evidence more relevant to their own clinical practices.

CONCLUSION

Clinical experience is relatively neglected by the EBM movement, but if that experience were systematically gathered through an approach such as EF, it would meet a need left unfulfilled by EBM.

A randomized effectiveness trial of a clinical informatics consult service: impact on evidence-based decision-making and knowledge implementation

OBJECTIVE

To determine the effectiveness of providing synthesized research evidence to inform patient care practices via an evidence based informatics program, the Clinical Informatics Consult Service (CICS).

DESIGN

Consults were randomly assigned to one of two conditions: CICS Provided, in which clinicians received synthesized information from the biomedical literature addressing the consult question or No CICS Provided, in which no information was provided.

MEASUREMENT

Outcomes were measured via online post-consult forms that assessed consult purpose, actual and potential impact, satisfaction, time spent searching, and other variables.

RESULTS

Two hundred twenty six consults were made during the 19-month study period. Clinicians primarily made requests in order to update themselves (65.0%, 147/226) and were satisfied with the service results (Mean 4.52 of possible 5.0, SD 0.94). Intention to treat (ITT) analyses showed that consults in the CICS Provided condition had a greater actual and potential impact on clinical actions and clinician satisfaction than No CICS consults. Evidence provided by the service primarily impacted the use of a new or different treatment (OR 8.19 95% CI 1.04-64.00). Reasons for no or little impact included a lack of evidence addressing the issue or that the clinician was already implementing the practices indicated by the evidence.

CONCLUSIONS

Clinical decision-making, particularly regarding treatment issues, was statistically significantly impacted by the service. Programs such as the CICS may provide an effective tool for facilitating the integration of research evidence into the management of complex patient care and may foster clinicians' engagement with the biomedical literature.

The use of postcolonialism in the nursing domain: colonial patronage, conversion, and resistance

The current context in nursing requires radical political analyses to deconstruct the dominant discourses that map both the discipline and the profession. In response to the strong reaction to articles, which critically examined the evidence-based movement in health sciences, we believe that it is essential to offer a perspective that is capable of resisting the progress of such discourses, which currently prevail in nursing and thus shape our profession. We believe that the biomedical model/ideology is a form of colonial patronage that is becoming more and more influential in nursing. Such colonization takes the forms of powerful discourses (eg, evidence-based medicine) and institutional practices that pervade all spheres of nursing: practice, research, education, and administration. In previous articles, we have criticized this trend; consequently, the objective of this article is not to replicate our previous arguments but rather to demonstrate that to what extent a postcolonial approach to nursing constitutes an efficient tool for disrupting the colonizing effects of the biomedical discourse.

No exit? Intellectual integrity under the regime of 'evidence' and 'best-practices'

No exit? Have we arrived at an impasse in the health sciences? Has the regime of 'evidence', coupled with corporate models of accountability and 'best-practices', led to an inexorable decline in innovation, scholarship, and actual health care? Would it be fair to speak of a 'methodological fundamentalism' from which there is no escape? In this article, we make an argument about intellectual integrity and good faith. We take this risk knowing full well that we do so in a hostile political climate in the health sciences, positioning ourselves against those who quietly but assiduously control the very terms by which the public faithfully understands 'integrity' and 'truth'. In doing so, we offer an honest critique of these definitions and of the systemic power that is reproduced and guarded by the gatekeepers of 'Good Science'.