Evidence Based Medicine: a movement in crisis?
It is more than 20 years since the evidence based medicine working group announced a “new paradigm” for teaching and practising 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. EBM became a buzzword, resulting in the Cochrane Collaboration and succesfull development of clinical practice guidelines. Physiotherapy joined the EBM bandwagon in the 21st century; this article is relevant for all critical minds in physiotherapy.
- The evidence based “quality mark” has been misappropriated and distorted by vested interests. In particular, the drug and medical devices industries increasingly set the research agenda.
- The volume of evidence, especially clinical guidelines, has become unmanageable.
- Statistically significant benefits may be marginal in clinical practice.
- Inflexible rules (eg a template for diabetes check-up) and technology driven prompts (quality points in the NHS) may produce care that is management driven rather then patient centred.
- Evidence based guidelines often map poorly to complex multimorbidity.
So, what is real evidence based medicine and how do we achieve it?
First of all, the care of the individual patient should be top priority: “what is the best course of action for this patient, in these circumstances, at this point in their illness or condition?” This requires an ethical and empathetic dialogue between patient and clinician, where needed supported with appropriate evidence that patients can understand.
Secondly, the research agenda must become broader and more interdisciplinary, embracing the experience of ill patients, present results in plain language (as offered by NICE), graphic and visual ways. Clinical training must extend to enhance expert intuitive decision making, and communicate both evidence and uncertainty with patients. Furthermore, to promote trust in evidence, independent funding of national bodies for medical research is crucial.
Much progress has been made and lives have been saved through the systematic collation, synthesis, and application of high quality empirical evidence. However, evidence based medicine has not resolved the problems it set out to address (especially evidence biases and the hidden hand of vested interests), which have become subtler and harder to detect. It is time to return to the movement’s founding principles—to individualise evidence and share decisions through meaningful conversations in the context of a humanistic and professional clinician-patient relationship.
> From: Greenhalgh et al., BMJ 348 (2014) g3725. All rights reserved to The Author(s). Click here for the Pubmed summary.