Evidence based medicine: a movement in crisis?

Posted on 21 April, 2015 – 9:59 AM

Greenhalgh, T., Howick, J., Maskrey, N.,Evidence based medicine: a movement in crisis? , 2014. BMJ 348 http://www.bmj.com/content/348/bmj.g3725 Available as pdf

This paper popped up in a comments made on Chris Roche’s posting on the From Poverty to Power website

Rick Davies comment: The paper is interesting in the first instance because both the debate and practice about evidence based policy and practice seems to be much further ahead in the field of medicine than it is in the field of development aid (…broad generalisation that this is…).  There are also parallels between different approaches in medicine and different approaches in development aid.

  • In medicine, one is rule based, focused on average affects when trying to meet common needs in populations and the other is expertise focused on the specific and often unique needs of individuals.
  • In development aid one is centrally planned and nationally rolled out services meeting basic needs like water supply or education and the other is much more person centered participatory rural and other development programs

I have written a blog in response to some issues raised in this paper here, titled  In defense of the (careful) use of algorithms and the need for dialogue between tacit (expertise) and explicit (rules) forms of knowledge

Excerpts from the BMJ paper

Box 1: Crisis in evidence based medicine?

  • The evidence based “quality mark” has been misappropriated by vested interests

  • The volume of evidence, especially clinical guidelines, has become unmanageable

  • Statistically significant benefits may be marginal in clinical practice

  • Inflexible rules and technology driven prompts may produce care that is management driven rather than patient centred

  • Evidence based guidelines often map poorly to complex multimorbidity

Box 2: What is real evidence based medicine and how do we achieve it?

Real evidence based medicine:
  • Makes the ethical care of the patient its top priority

  • Demands individualised evidence in a format that clinicians and patients can understand

  • Is characterised by expert judgment rather than mechanical rule following

  • Shares decisions with patients through meaningful conversations

  • Builds on a strong clinician-patient relationship and the human aspects of care

  • Applies these principles at community level for evidence based public health

Actions to deliver real evidence based medicine
  • Patients must demand better evidence, better presented, better explained, and applied in a more personalised way

  • Clinical training must go beyond searching and critical appraisal to hone expert judgment and shared decision making skills

  • Producers of evidence summaries, clinical guidelines, and decision support tools must take account of who will use them, for what purposes, and under what constraints

  • Publishers must demand that studies meet usability standards as well as methodological ones

  • Policy makers must resist the instrumental generation and use of “evidence” by vested interests

  • Independent funders must increasingly shape the production, synthesis, and dissemination of high quality clinical and public health evidence

  • The research agenda must become broader and more interdisciplinary, embracing the experience of illness, the psychology of evidence interpretation, the negotiation and sharing of evidence by clinicians and patients, and how to prevent harm from overdiagnosis

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