The Evidence-Based Medicine renaissance: holy grail or poisoned chalice?

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Jeremy Howick

Dr Jeremy Howick on the evidence-based medicine renaissance

Today at our Health Services Research Conference, Professor Trish Greenhalgh announced her new campaign for Real Evidence-Based Medicine. In this guest post, her fellow campaigner Dr Jeremy Howick writes about why we need a renaissance in Evidence-Based Medicine.

A meeting involving critics and proponents of Evidence-Based Medicine (EBM) took place in September 2013 to discuss how to overcome current problems with EBM.

Led by Trish Greenhalgh, the meeting attendees wrote an editorial that was published last week in the BMJ. The article – Evidence based medicine: a movement in crisis? – argues that the many benefits of EBM have too often been obscured by undesirable and often unintended consequences including:

  1. Misappropriation of EBM by vested interests. These interests are often commercial, but also include managers who use guidelines to control practitioners. Ironically while these guidelines are touted as ‘evidence-based’ they often lack a sound evidence base.
  2. An unmanageable volume of evidence being produced
  3. Statistically significant but clinically irrelevant benefits being exaggerated in large trials and systematic reviews that report relative rather than absolute effects.
  4. A mismatch between the evidence produced and the complex demands of clinical practice, where patients often present with a complex mix of psychological, physiological, and social problems, as well as other comorbidities.

The editorial has been a real hit, with thousands of views and downloads, as well as over 30 rapid responses. There is clearly a thirst for a renewed and refreshed version of EBM that helps achieve EBM’s stated aims.

The success of the editorial, however, is a double-edged sword. Complementary and alternative practitioners like the editorial because they can use it to point out that conventional medicine is not based on (good) evidence.

Commercial interests will use it to undermine evidence suggesting their treatments don’t work. And without Herculean efforts (that go far beyond writing a beautiful article) the tide of the growing number of publications will not be stemmed.

microscope

Trish Greenhalgh is putting evidence-based medicine under the microscope

Meanwhile, the central and simple message of EBM, namely that the best research evidence needs to be combined with patient values and circumstances, along with practitioner expertise, threatens to get buried under a mass of nebulous and heterogeneous critique. This will take us further away, and not closer to our goal of using the best evidence to improve patient care.

The success of the renaissance depends on setting up and acting on an agenda that reinstates the core values of EBM so that patients benefit. If anyone is up to this task, it is Trish Greenhalgh, who will be giving a talk about her concrete plans to lead this renaissance as part of a session on Implementation Science at the Health Services Research conference, entitled ‘The Campaign for Real EBM’.

Talking about her plans, she envisages: “a situation where doctor and patient collaboratively set the agenda and share decision-making in a more emergent way, guided and supported by tools that both reflect best research evidence … and also prompt discussion about what matters to this patient”.

Our interests as clinicians, policy makers, researchers, and (potential) patients are at stake!

  • http://www.daktre.com/ NS Prashanth

    Very interesting. While I can indeed see the immediate meaning of the article for most of the western world, the message is very difficult to translate, for example in Indian settings. We here live in a very poorly regulated, private healthcare dominated (ranging from individual private doctor-entrepreneurs to large corporate chains), pluralistic (modern medicine, Ayurveda, homeopathy, Siddha etc etc) health system. EBM has yet not made enough inroads into our health services (and system). I am now wondering if that is somewhat an opportunity to understand its evolution better in those settings and “translate” it to our settings.