Extending the study of evidence-based medicine

Evidence-based medicine (EBM) is an approach to medical practice intended to enhance decision making, recognizing that only the strongest study types can yield strong recommendations. Trish Greenhalgh explains more here.

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Many people, myself included, owe their lives to evidence-based medicine (EBM). We have benefited from trials and observational studies that have informed early diagnosis, effective treatments and systematic follow-up for our condition(s). But as the Evidence-Based Medicine Renaissance Group argued recently, the movement’s indisputable successes are no cause for complacency.

A generation of false summits and misplaced enthusiasm has demonstrated that randomized trials, observational cohort studies and systematic reviews, even when well conducted and ‘unbiased’, do not take the politics out of policymaking or substitute for individual clinical wisdom or organisational memory.

Contrary to initial expectations, the accumulating evidence base from clinical epidemiology is not the truth that will improve human health and well-being, but a partial, partisan and contestable version of that truth.

Researching beyond the concepts and methods

Most questions surrounding the application and use of those tools and techniques in the real world require interdisciplinary research that goes beyond epidemiological concepts and methods.

It is therefore time to contextualize EBM and extend its study beyond the tools and techniques of clinical epidemiology (what might be called EBM’s ‘internal validity’).

Most questions surrounding the application and use of those tools and techniques in the real world (EBM’s ‘external validity’) require interdisciplinary research that goes beyond epidemiological concepts and methods. For example:

  1. Research evidence, however ‘robust’, is not politically neutral. Rather, it is generated, interpreted and used in particular contexts by and for particular interest groups. Hence, EBM needs to interface with political science.
  1. EBM is implemented by people, who necessarily make judgements and bring their assumptions, values and cognitive biases to bear on that process. Hence, EBM needs to interface with cognitive psychology.
  1. People are influenced (to a greater or lesser extent) by other people. They form groups, teams and networks in which evidence is discussed, negotiated and accorded meaning and significance. Hence, EBM needs to interface with social psychology.
  1. EBM is implemented (or not) in organizations, which have particular cultures, climates, traditions, routines and ways of working. Hence, EBM needs to interface with organizational science.
  1. The principles and empirical findings of EBM may be built into computerised decision support systems, which (like all computer systems) both shape and constrain the work they were designed to support. Hence, EBM needs to interface with computer science.
  1. Answers to questions about what is the case do not necessarily help us to address the question ‘what ought to be the case?’ Hence, EBM needs to interface with moral philosophy.
  1. The world is not a clockwork universe. Much of the science of clinical epidemiology is about generating predictive statements about the relationship between variables under carefully controlled conditions. Whether and how these statements apply to the messy and rapidly changing open systems of real-world health and social care is a completely different question. Hence, EBM needs to interface with complexity science.

And so on. The series ‘Extending EBM’ runs across the BMC suite of journals and seeks to develop these and other interdisciplinary avenues in a way that upholds the fundamental principles on which EBM was founded.

So far in the series

The first four articles in the ‘Extending EBM’ series considered the role of values in EBM, the socio-political context of randomised trials, the ‘hidden biases’ that can occur against patients and carers (due largely imbalances of power and perspective within and beyond the clinical consultation), and the aspiration-reality gap in shared decision-making.

Each of these articles combines an acknowledgement of the important contribution of EBM with an additional disciplinary perspective that helps explore, explain or question how EBM is applied in practice.


Submitting to the series

These four articles kick off a series that looks critically, but constructively, at EBM through an interdisciplinary lens. We now wish to add to that series.

To that end, we invite submissions of 300-word abstracts giving a title, a summary of the argument, and a suggested target journal in the Biomed Central portfolio of journals. Abstracts judged (by the overall series editor – me – and the editor(s) of the relevant journal) to meet the goals of the series will be invited to submit a full paper which will be sent for peer review. Publication fees are the responsibility of the submitting authors.

Please send your abstracts for the series to trish.greenhalgh@phc.ox.ac.uk. There is no deadline for submissions to this series, but suitable abstracts will be taken forward on a first come, first served basis.

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Kit Byatt

An excellent initiative – at last, a powerful drive towards making the important measurable, rather than the measurable important. McNamara’s fallacy (in the context of EBM) is at last being challenged!
One question: might anthropology, chaos theory, and game theory usefully be added to the above list?

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