Evidence based practice (not medicine): perspectives of an editor Richard Smith Editor, BMJ www.bmj.com/talks
What I want to talk about • What is evidence based practice? • Evidence based practice: a personal history • Reflections on whether evidence based practice is radical • Making evidence based practice a reality • Where now? • Conclusions
Mark Twain on evidence based practice “It ain’t what people don’t know that hurts them, it’s what they know that ain’t so.”
Illustrating Mark Twain’s point • Keeping patients in bed after myocardial infarcts • Giving lignocaine to all patients who have had infarcts • (Taking 14 years to understand that thrombolytic therapy works in patients after infarcts)
What is evidence based practice? • “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” BMJ 1996; 312: 71-2.
What evidence based practice is not • Something we’ve been doing for ages • Only possible in ivory towers • “Cookbook” medicine • A tool of managers and insurers • Restricted to randomised trials and systematic reviews • Antipathetic to patient centred medicine
The essence of evidence based practice • Allevidence is sought and examined systematically • Evidence is wherever possible quantified • Evidence is considered inAlldecisions in healthcare • Evidence doesn’t make decisions: human beings do
Evidence based practice: a personal history • 1952--born: tabula rasa • 1959--tonsils and adenoids removed, so unable to play Archangel Gabriel in school nativity play • 1969--study experimental science and understand that all scientific truths are provisional
Evidence based practice: a personal history • 1973--complete a degree in experimental pathology, understand the weakness of the scientific base of much of pathology • 1974--start studying clinical medicine; worry that much of it seems to be for the benefit of doctors not patients
Evidence based practice: a personal history • 1974--hear Ivan Illich argue that “modern medicine is the major threat to health in the modern world”; drop out of medical school for two days; blown permanently off course • 1975--win a prize for an essay on “the threat of modern medicine”; understand the dangerousness of the enterprise; learn that increases in life expectancy have not been the result of medical care
Evidence based practice: a personal history • 1976-79--work as a junior doctor, understand how ineffective and dangerous I am; see this primarily as a personal failing • 1976--routinely treat patients who have had myocardial infarcts with intravenous lignocaine • 1979--join the BMJ; begin to understand the weakness of much medical research
Evidence based practice: a personal history • 1981--son Freddie born, wife, Lin, is given an enema, has pubic hair shaved, and is given an episiotomy; assume that this must be best treatment • 1982--write a series of articles on alcohol problems; discover that nobody can define “alcoholism,” that many people get better without any treatment, and that nobody has ever done a trial of “usual treatment” against no treatment; assume that this is a failing unique to psychiatry
Evidence based practice: a personal history • 1989--read a paper by David Eddy pointing out that usual treatments of glaucoma are not based on any evidence; the evidence that is available suggests the treatments will make the problem worse • 1991--third child, Florence, born; all the interventions that Lin had in 1981 have disappeared • 1992--as editor of BMJ, publish “The scandal of medical research,” which argues that most clinical research is of poor quality
Evidence based practice: a personal history • 1994--attend the first Cochrane colloquium in Oxford • 1994--read the phrase “Evidence based medicine” for the first time • 1995--plan to launch “International Journal Club”; Dave Sackett suggests we call it “Evidence Based Medicine”; publishing colleagues have never heard the phrase and think the title absurd
Evidence based practice: a personal history • 1995--I make a television programme that argues that medicine is driven more by fashion than science • In the first shot I sit on the grave of a woman who died with rheumatoid arthritis; she had been treated by having all her teeth removed and with raw liver sandwiches, high dose steroids, and NSAIDs. Before she died she asked her GP: “Would I have done better if I’d simply taken aspirins?”
Evidence based practice: a personal history • 1996--by the end of the year most British doctors have heard the phrase • 1996--he British minister of health has declared that his main mission is to promote evidence based medicine • 1996-The phrase has appeared on the front page of one of Britain’s highest selling newspapers
Evidence based practice: a personal history • 1995--Tom Mann from the Department of Health suggests to me that we produce “a BNF of evidence” • 1999--Clinical Evidence--”a compendium of evidence based answers to questions on treatment”--published • 2000--We sell 500 000 copies of the first 10 issues (until 2003) in the US
Evidence based practice: a personal history • 2001--An article appears that the craziness of EBM flourished in Britain only because the BMJ got into bed with it • 2002--Clinical Evidence is available in French, German, Italian, Japanese, Spanish, and Russian • 2002--Launch of besttreatments.org, a website for patients and physicians based on Clinical Evidence
Is evidence based practice a radical change? • Combines with other drivers of change • “Consumerism”; the resourceful patient • The arrival of the internet • The desire of owners to manage more the clinical process • Growing gap between what could be done and what can be afforded
Old world: Source of knowledge is expert opinion New world: Source of knowledge is systematic review of evidence Has EBP changed the world?
Old world: Clinical skills are seen as semi-mystical New world: Clinical skills can be audited and managed Has EBP changed the world?
Old world: Research is marginal to practice New world: Research and practice go together Has EBP changed the world?
Old world: Analysis of research is haphazard New world: Analysis of research is systematic Has EBP changed the world?
Old world: Not important to gather new evidence from patients routinely New world: Patients should be included in trials wherever possible Has EBP changed the world?
Old world: Main information sources are experts, selected journals, and books New world: Essential to have immediate (electronic) access to systematically collected evidence Has EBP changed the world?
Old world: Most of what doctors need to know is in their heads New world: Doctors must use information tools constantly Has EBP changed the world?
Old world: Only lip service is paid to keeping up to date and learning new skills New world: Essential to keep learning new skills Has EBP changed the world?
Old world: Most medical care is assumed to be beneficial New world: Widespread recognition that the balance between doing good and harm is fine Has EBP changed the world?
Old world: Clinical performance is not systematically audited New world: Clinical performance is regularly reviewed and managed Has EBP changed the world?
Old world: Managers have little involvement in clinical proceses New world: Managers are involved in clinical processes Has EBP changed the world?
Old world: Organisational model is hierarchical New world: Organisational model is much more democratic, based on ability to use evidence Has EBP changed the world?
Old world: Doctor patient relationship is essentially master/pupil New world: Patient partnership is the norm Has EBP changed the world?
Old world: Patients do not have easy access to the knowledge base of doctors New world: Patients have as much access to the evidence base of medicine as doctors Has EBP changed the world?
Old world: The doctor is smartest New world: Often the patient is smarter Has EBP changed the world?
Making EBP a reality • Original model of doctors posing questions and searching and appraising the literature is unworkable • No time • Inadequate skills • Doctors need to be helped with what the evidence says
Information sources • Cochrane library • Centre for Reviews and Dissemination • Clinical Evidence • EB guidelines--for example, SIGN (Scottish Intercollegiate Guideline Network) • NICE (National Institute for Clinical Excellence) • Many others in other countries
Problems with information sources • Mostly cover only treatment--evidence based information on diagnosis, prognosis, harms, etc is much trickier • Patchy--don’t cover everything • Maybe hard work to access
Problems with information sources • Too slow • Don’t deliver information tailored to individual patients • Guidelines must give guidance even when the evidence is incomplete--very tricky, culturally bound, may ignore the patients’ wishes
Making change happen • Information alone rarely changes behavior • Change is hard to achieve • Just in time information • Improvement techniques • Small group education
Making change happen • Marketing • Through patients • Command • Incentives--sticks and carrots
The future • Improving information sources • Finding ways to make change happen • Involving patients • Spread to all parts of healthcare and beyond • Spread to all parts of the world
Conclusions • EBP has swept the world in less than 10 years • The appearance of EBP does mark a radical break from the old world • It is a new world in which the traditional authority and skills of doctors are questioned • There are many ways in which it might/will develop
Conclusions • Information on its own doesn’t change practice • We must learn more about how we move from evidence to change, but we know it’s hard
Finally • “When a steamroller comes through you are either part of the roller or part of the road.” • Stuart Brand