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The New Role of Evidence Based Medicine Walter Rosser, MD,CCFP,FCFP,MRCGP (UK) Professor and Head Department of Family Medicine Queen’s University Kingston, Ontario, Canada Rosser, Walter. “The New Role of Evidence Based Medicine.” [Online] 10 September 2004.
Plan for Discussion Introduction Criticism Against Evidence Based Medicine A New Role for EBM Some Tools of Value to the Practitioner Conclusion/Discussion
Introduction The concept of evidence based medicine has been evolving over the past 30 years. Methods to critically appraise clinical information and classify it according to the strength of evidence (A,B,C,D,E.) was first presented in a Canadian Medical Association Journal series on how to critically appraise literature in the early 1980’s.(1)
Introduction In the late 1980’s and early 1990’s, the Journal of the American Medical Association published a similar series on how to critically appraise literature. (2) Concepts emerging from the literature on “critical appraisal” promoted what has become known as evidence based medicine (EBM), suggesting that clinicians should use critically appraised information in clinical practice for optimal care of their patients
Criticizing EBM Attempts over the past 1 ½ decades to implement EBM in Canada, the United States, the UK and Europe generated a controversy that has questioned the value of EBM in clinical practice. (3) Many practicing physicians regard EBM as an academic exercise for medical students that has no relevance to clinical practice Often the translation of results from RCT’S conducted in teaching hospitals is not appropriate for Family Practice (4)
Criticizing EBM It is impossible for any clinician to have the time to critically appraise even one article per week let alone the number that would need to be appraised to answer questions (estimated at 3.5 per clinical session) arising in a busy practice. Governments, hospitals and HMO’S have used the jargon of EBM to justify decisions, directives, or incentives that are seen by clinicians as inappropriate.
Criticizing EBM Critically appraised “evidence” has been used to support politically inspired justification for what are perceived by clinicians as “bad” decisions that are not in the best interests of patients or the institution. EBM is seen by some to promote “therapeutically nihilistic” approaches to medical practice since critical appraisal of commonly used therapies often concludes that they provide little or no benefit
EBM is also said by some to promote “cook book” medicine, using evidence from population-based randomized controlled trials to dictate required treatments, irregardless of the physician’s judgment or the patient’s wishes. Family physicians often find that EBM often does not address or answer questions that arise in their practice. Criticizing EBM
Some practitioners find that evidence based therapy is different than the standard practice in their community and worry about increased medical-legal risk There is an argument that EBM has made generalist medical practice less attractive to medical students for a career.(5)
Criticizing EBM The student argument is that to be a good physician, you must know everything there is to know in your field and this is only possible in narrow subspecialties. Resistance to adopting EBM has created a “Time Gap “ between development of research proven evidence of good or poor therapy and widespread adoption that has been estimated as long as 15 years.
A New Role for EBM How can all these concerns be addressed? How can the individual clinician deal with the time required to properly critique even one article per week let alone what is needed in practice? As a first step, all practicing physicians need to understand the basic principle of EBM and critical appraisal.
A New Role for EBM There are at least two reasons that support this statement. By understanding the principles of EBM, clinicians can critique third party sources that provide evidence based information so they can be confident about the quality. They may also need to rapidly assess quality of studies that are sensationalized in the popular press and often bring patients into the office with demands or questions.
A New Role for EBM There are a growing number of organizations and agencies that are using very transparent methods to critically appraise literature on common medical problems and choosing the best available evidence. An example of such a site that chooses the best available guidelines is www.gacguidelines.ca www.gacguidelines.ca A list of other critically appraised sites is available on Table 1.
A New Role for EBM If all practitioners had the skill to: Do a rapid literature search on one or two search engines Rapidly critically assess the media’s study of the week Be able to judge the quality of critically appraised information provided by a third party, …then the gap between evidence and practice would quickly narrow.(6)
A New Role for EBM Presence of an internet connection in every practitioner’s office will signal a revolution in the practice of Family Medicine. Basic information about any problem or symptom, no matter how rare or unusual, can be obtained within a few minutes by the clinician. Best available evidence, recently updated is there for any patient within the time constraints of a visit to a busy practice.
A New Role for EBM While the clinician can access whatever information is needed in the office, he/she may also receive education while integrating EBM into practice. CAPRE stands for “critically appraised practice reflection program” which includes identifying a patient with a specific problem, providing the patient with EBM information answering their questions and then determining if they did or did not follow the advice. The CAPRE program is at www.meds.queensu.ca/capre www.meds.queensu.ca/capre
A New Role for EBM The final step, all on line, is to feed back to the program a description as to whether the patient adopted the recommendations or not, and for the physician to self assess to determine if he or she might have presented the information more effectively. The new role of EBM is in assisting the physician in diagnosing and managing their patients and being educated on line
Some EBM Tools The GAC site provides an example of the new generation of web based tools.(9) The site is jointly sponsored by the Government of Ontario and the Medical Association. Medical librarians do literature searches on common problems selected by a consultation process between physicians and the government health insurance plan.
Some EBM Tools All guidelines on the topic are identified (23 on asthma) The guidelines are then scored by 3 trained community physicians (there are 80 available) using a validated scoring system. (Cluzeau) Scored guidelines are then rank ordered and assigned an “apple” score according to the quality of critical appraisal methods used to produce the guideline. 4 apples = excellent, 3 apples = good, 2 apples = fair, 1 apple = poor.
Some EBM Tools The best available guideline is then summarized on one page so the practicing clinician can easily access the information they need in their office. See attached copy of the example Asthma: Inhaled Glucocorticosteroids in Adults and Children (10)
Some EBM Tools The table labeled “Some foraging tools” offers a list of some of the available EBM materials taken from the book titled “Evidence Based Family Medicine”(7) The table titled “Some EBM Web sites” is similarly drawn from “Evidence Based Family Medicine” These tables provide you with an idea of what is available to assist incorporating EBM into practice.
Some EBM Tools The Book “Evidence Based Family Medicine” includes a CD-Rhom that hotlinks all these sites. The book references other programs like the GAC web site and the CAPRE web site. (8) CAPRE provides patient information and a physician/patient partnership program that includes written agreement between physician and patient over evidenced based approaches to therapy. (See example in handout)
Some EBM Tools For those interested in teaching EBM, the CD Rhom accompanying “Evidence Based Family Medicine” includes a series of ideas on how to teach critical appraisal in four different environments: The clinic Small groups Web based courses Using the Bedford Murder
Some EBM Tools The Bedford Murder is a murder mystery built around learning critical appraisal principles.(11) As the mystery unwinds, questions arise about the likelihood of a character contracting a disease or dying of cardiovascular disease in the next 10 years. This strategy breaks the image of EBM being only for academics.
Some EBM Tools Use of hand held systems providing evidence based information is presently available and provides promise for the future of incorporating EBM into every practice. “Info Retriever” is the most widely used tool for this purpose
Conclusion EBM is not widely accepted by practitioners as a good approach for clinicians The argument of its necessity for practice of medicine has been presented Some tools to assist us in using and teaching students and residents how to incorporate EBM into their practice are offered. These ideas should stimulate some discussion and your opinions about the value and need for EBM