One of my all-time favourite medical or scientific journal articles discusses evidence-based medicine, or EBM. And parachutes. To avoid any confusion on the EBM side, let’s talk about that for a moment.
I’ll get to the parachutes – I promise!
Researchers at McMaster University, here in Canada, have been credited(1) with the first use of the term evidence-based medicine; as far back in the 1990s. The definition at that time was: “a systemic approach to analyze published research as the basis of clinical decision making”.(1)
a systemic approach to analyze published research as the basis of clinical decision making”.(1)
The more popular definition seems to be the one set out by Sackett et al in 1996: “the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients”.(2)
the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients”.(2)
On the surface, there doesn’t seem to be anything controversial in either of these two statements. Yet EMB has become controversial, and seems poised to become more so. And this is why I find the issue so interesting from a bioethics perspective; because this controversy can directly impact patient care.
Let’s go back to these two definitions of EBM. The first strikes me as a call for the analysis and synthesis of research findings into clinical practice guidelines. This makes sense, given the volume of healthcare research published in any given year. I can’t imagine that any clinician is able to read all of these results.
And clinical practice guidelines are just that; guidance to clinicians in the care of individual patients. It’s expected that, in some cases – based on a specific patient’s comorbidities, family history, etc. – a clinician will agree with patient not follow the guidelines. That they will instead opt for a treatment plan (or none) that better suits the peculiarities of that particular one case.
Assuming that a clinical practice guidelines exists, the second statement calls only for its “conscientious and judicious use”(2) by clinicians. This concept, however has been taken by some as a call to only provide treatment based on EBM.
This more contentious viewpoint can be interpreted as advocating for the removal of clinical expertise and experience from the exam room. Of perhaps replacing the ‘art and science’ of medicine’ with the ‘robot of medicine’.
In some circles, then, EBM is seen as an attack on medical practice which combines research evidence with a physician’s own clinical experience. Which, in my area, seems to be how most clinicians practice.
A strict adherence to EBM would seem to suggest that they set aside or otherwise ignore some – or all? – of the expertise they’ve gained through treating patients as individuals. It suggests that a computer could better care for their patients.
Technology has had a large role in the advancement of EBM. Computers and database software have allowed compilation of large amounts of data. The Index Medicus has become a medical dinosaur of the past that students of today likely do not recognize. The Internet has also allowed incredible access to masses of data and information.
However, we must be careful with an overabundance of “unfiltered” data. As history, as clearly shown us, evidence and data do not immediately translate into evidence based practice.”(1)
Now that we have at least an idea of the type of controversy surrounding EBM, let’s get to those parachutes! The journal article to which I referred earlier, as my all-time favourite, is a satirical take on EBM, published in the BMJ 5 years ago this month. It begins from the position that:
The perception that parachutes are a successful intervention is based largely on anecdotal evidence. Observational data has shown that their use is associated with morbidity and mortality, due to both failure of the intervention and iatrogenic complications… We therefore undertook a systematic review of randomised controlled trials of parachutes.”(3)
To get a taste of the sarcasm at play in this piece, consider the phrases: “We excluded studies that had no control group”(3) and “studies are required to calculate the balance of risks and benefits of parachute use.”(3) Are you smiling yet?
Another highlight of this work is:
The widespread use of the parachute may just be another example of doctors’ obsession with disease prevention and their misplaced belief in unproved technology to provide effective protection against occasional adverse events.”(3)
I highly recommend reading this article over the holidays, for a lighter take on a serious topic. And take with a grain of salt the closing line of this satire:
we feel assured that those who advocate evidence based medicine and criticise use of interventions that lack an evidence base will not hesitate to demonstrate their commitment by volunteering for a double blind, randomised, placebo controlled, crossover trial.”(3)
As for my personal bioethical perspective on this, it’s that there should be a balance between EMB and clinical expertise in medicine; what those who call for a complete embrace of EBM would no doubt call anecdotal. Or anec-data. No clinician should disregard solid new research showing that a preferred treatment is not as efficacious as they’d believed, while proponents of EBM shouldn’t expect them to disregard their expertise in the care and treatment of patients. A Socratic moderation, if you prefer; as with so much else in healthcare, and with health in general.
It’s about integrating individual clinical expertise and the best external evidence”(2)
EBM is not about replacing clinical expertise – combined with in-depth knowledge about individual patients – with some kind of mainframe or automated system. The goal shouldn’t be to replace clinicians with computers, for robots to take over the one-on-one trust relationship that exists in best clinical care situations, it should be providing the best care possible to patients. As always.
Happy holidays, and best wishes for 2008!
References:
(1) Claridge, J.A. & Fabian, T.C. History and development of evidence-based medicine. World J. Surg. (2005) 29: 547. May 2005. On-line. Accessed 20 Dec 2007: https://link.springer.com/article/10.1007%2Fs00268-005-7910-1
(2) Sackett David L, Rosenberg William M C, Gray J A Muir, Haynes R Brian, Richardson W Scott. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312:71. On-line. Accessed 20 Dec 2007:
https://www.bmj.com/content/312/7023/71.full
(3) Smith, Gordon C.S. & Pell, Jill P. Parachute use to prevent death and major trauma related to gravitational challenge: Systematic review of randomized clinical trials. BMJ. 18 Dec 2003; 327:1459. On-line. Accessed 20 Dec 2007: https://www.bmj.com/content/327/7429/1459