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Evidence-Based Medicine |
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Written On: March 2006 |
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Written By: by Ron Dalby |
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For a little more than a dozen years, "evidence-based medicine" has been one of the new buzzwords—or phrases—in medical circles. The term was coined in the early 1990s at McMaster University in Ontario, Canada, by a group of clinicians and epidemiologists. It has not yet gained universal acceptance by medical practitioners. Perhaps the biggest complaint is that it is just too cumbersome to integrate into an existing medical practice.
Using Evidence-Based Medicine
In one sense, your doctor has always used a form of evidence-based medicine to determine treatment for an injury or illness. He or she listened to your tale of woe, perhaps ordered one or more tests in the lab or diagnostic images, and poked and prodded as you sat on the examining table. All of these things provided your doctor with information, or evidence, if you will. From this a diagnosis was derived and a regimen of treatment was prescribed. That treatment might involve medications, a change in lifestyle, surgery or other options. On occasion, if you really confused your physician, he or she might leave you sitting in the exam room for a brief period to quickly look something up in a medical journal or other reference.
Particularly if your doctor ran out of the room to do a moment's worth of research, he or she was at least operating on the fringes of what is today called evidence-based medicine.
According to the Centre for Evidence-Based Medicine (www.cebm.net), "Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."
McGill University, in their pre-med curriculum, goes further, saying: "Evidence-based medicine can be viewed as a process consisting of four core skills, including:
• Formulating focused and answerable clinical questions born out of the uncertainty that arises in the diagnosis and management of patients.
• Searching for best evidence through the selection and efficient navigation of online resources that can address the question.
• Critical appraisal (validity of research methods, strength of results, applicability) of the research evidence retrieved.
• As viewed through the perspective of patient values and the clinical context, integrate best evidence into decision-making as it pertains to the evaluation, care and education of patients."
The Medical Journal of Australia simplifies these four concepts:
• Asking answerable questions.
• Accessing the best information.
• Appraising the information for validity and relevance.
• Applying the information to patient care.
Perhaps the key phrase in all of these defining concepts is the term "best evidence" in the original definition. While all facts gathered by your doctor in relationship to your illness or injury can be considered evidence, some facts—or items of evidence—are likely to be of higher quality or more important than others. Thus the concept behind evidence-based medicine is that your physician makes decisions based on the best evidence of the potentially thousands of pieces of information that may in some way pertain to your situation.
The problem becomes one of determining which pieces of evidence are best for any given patient. And it is very possible that what is best for one patient is not necessarily best for another patient facing a similar malady.
Researching Best Evidence
Dr. David Sackett, who wrote the original definition of evidence-based medicine given above, added a second sentence to the definition which is not used as often. It states, "It means integrating individual clinical expertise with the best available external clinical evidence from systematic research."
The biggest problem with research is the sheer volume of information available. By way of example, enter the phrase "evidence-based medicine" into the online search engine Google and you’ll get more than 8 million hits.
In regards to this wealth of information, the Medical Journal of Australia recently reported on a 1989 survey of 625 primary-care physicians and 100 physician opinion leaders in the United States. Some 65 percent of these doctors claimed then that the current volume of scientific information was unmanageable. When asked about recent medical advances, these same doctors demonstrated deficiencies that would affect patient care. And—here’s the kicker—in the 17 years since this study was made, total biomedical knowledge has increased by a factor of 50 percent or more.
Three-quarters or more of Australian physicians surveyed listed either insufficient time, limited research skills or limited access to evidence as reasons for not making full use of the best research data available.
With the growing use of the Internet in almost all fields of endeavor, the needed information is out there and available. Thus lack of time and poor research skills become the critical problems. Many, perhaps most, doctors are unwilling or perhaps feel unable to leave a patient sitting in an exam room while they access the Internet for online information pertinent to the case at hand.
This problem does, however, seem to be slowly evolving. More and more physicians are actually putting computers into exam rooms with Web sites appropriate to their practices listed under "Favorites" for quick and easy access. Thus they can access information within seconds and with the patient available in the room in case additional questions arise. The growing use of PDAs in the hands of physicians also allows quick access to Internet-based information—even while making rounds in a hospital.
Costs
Evidence-based medicine is not necessarily a means of cutting costs. It is only a method of looking for the most effective ways to treat patients—to improve both the quality and quantity of their lives, according to the General Practice Notebook, a United Kingdom medical encyclopedia on the World Wide Web (www.gpnotebook.co.uk). In fact, depending on what a doctor’s research uncovers, the cost of treatment might actually go up.
Does It Work?
The Centre for Evidence-Based Medicine claims that population-based outcomes research has documented that patients receiving evidence-based treatments have better outcomes than those who don’t. They do, however, qualify this comment by noting that no such evidence is yet available from randomized trials because no one has yet overcome the problems of sample size, contamination, blinding and long-term follow-up which these kinds of trials require.
According to Wikipedia, a free online encyclopedia, critics of evidence-based medicine are wont to claim that doctors who employ it are more apt to make their decisions based on clinical research with less attention paid to what is best for the patient.
That criticism aside, however, Wikipedia goes on to note that evidence-based medicine is fast becoming the "gold standard" for clinical practice and treatment and that it is most used when the treatment regimen is a medication of some sort. Of all the treatment regimens available to doctors, the various drug therapies are the ones most likely to be adequately tested and reviewed simply because anything involving the patient more directly is fraught with opportunities for errors.
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