AGAINST

AGAINST

by Sultana Azam -
Number of replies: 8

This house believes EBM isn’t all that great!

EBM has been a revolution and paradigm shift in clinical practice and thinking. Countless guidelines have been published by groups such as NICE and many more are certainly to com.  Guidelines are undoubtedly part of good clinical practice and are a way of standardising good quality healthcare across various clinical settings. However, should these guidelines be absolute? If so, how valid are they? Or are there various leeways (flexibilities) that clinicians/health professionals can practice within?

EBM does clearly has its advantages, I don’t think there is much point discussing the technical faults that EBM can have. However, there are other multidimensional effects of EBM practice. Below are a few points:

 My main issue with EBM is the validity and reliability of the data provided as a basis for clinical practice. Vested interests and pharmaceutical funding can influence the findings of such data.

http://theconversation.edu.au/pharmas-influence-over-published-clinical-evidence-5325

Often, positive findings are more likely to be published than negative findings. This can have detrimental effects on clinical decision making.

http://www.ted.com/talks/ben_goldacre_what_doctors_don_t_know_about_the_drugs_they_prescribe.html

EBM generally uses quantitative research, this usually comes from RCTs but are RCTs are not relevant for all treatment settings e.g. prognostic questions in pregnancy rates following IVF. Moreover, there is often a lag time between conducting the RCT and publishing, could this effect clinical practice?

These studies may not be representative of all studies in the field. They might only be relevant to a certain population/ethnicity. Guidelines published in the UK may not be applicable to other countries worldwide.

For example, TB diagnosis in the UK may include Sputum sampling, CXR, Mantoux test BUT in countries such as Bangladesh there may not be the resources available to carry out routine CXRs/Mantoux tests. EBM works best when there are infrastructural elements to the health care system. EBM requires funding and in lower income countries this could open the door to Pharmaceutical companies taking advantage.

1)      Validity and Reliability of the data

2)      Pharmaceutical funding

3)      What gets published

4)      RCTs seen as gold standard method of data collection for EBM

5)      Reproducible worldwide

In reply to Sultana Azam

Re: AGAINST

by Deleted user -

Well done Sultana! You made your points well understood. However, I strongly disagree that poorer countries have less opportunity to use EBM.

In Turkey, most patients end up having unnecessary interventions pharmaceutically and surgically because of the lack of standards and guidelines based on evidence and cost analysis. 

On the other hand, I agree that EBM is rigid in its nature and misses out very essential domain of doctor-patient relation sometimes. But then, this has recently been more recognised and "doctor's discereation" in the some guidelines started appearing.

As a junior doctor I belive, I need some rules conveying EBM into medicine and the flexibility in interpreting and conducting these rules will come with experience.  

In reply to Deleted user

Re: AGAINST

by Deleted user -

Thanks Sultana and Filiz

 But I guess then that the contention is whether discretion should be exercised 'pre' or 'post' EBM. Assuming that it is not easy to apply discretion particularly where EBM is very strict about the do's and dont's. A Clinician might not always be confident to exercise thier intuition particularly where there are sensitive issues related to culture or moral obligations.

In reply to Deleted user

Re: AGAINST

by Moira Kelly -

Some very interesting points made so far.  A couple of questions from me:

Does medicine need evidence?

What types of evidence should medicine draw upon?

In reply to Moira Kelly

Re: AGAINST

by Jacqueline Nabuala Walumbe -

In answer to Moira’s question, I can use the example of management of low back pain as a clear case where medicine does in fact need evidence. 20 years ago, the management of this apparently simple ailment was anybody’s guess. Orthopaedics performed multiple surgeries leading to the phenomenon of ‘failed back surgery’, prescriptions for analgesic medication increased in primary care, the emergence of professions allied to medicine spawned a whole host of interventions purported to cure back pain, alternative health has acquired a share of the market to health consumers dissatisfied with the current provision. One would think that given the sheer scale of vested interest, back pain, like small pox would be a rarity. This is not the case.

See http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2729142/

We only know this by applying the principles of EBM to low back pain. Epidemiology to map the scale of the problem, trials to assess the efficacy of the interventions allowing risks and benefits to be outlined, guidelines to assist clinicians in making decisions about what interventions and all of these to assist commissioners in deciding which services are worth investing limited resources to. There is now good quality evidence to support clinical practice. Nice produced a guideline on the management of low back pain with clear recommendations as to what is supported by evidence or not. ( http://www.nice.org.uk/nicemedia/live/11887/44345/44345.pdf)

Spinal injections and complex medication regimes were not presented in a favourable light. The president of the British Pain Society was ‘ousted’ for his role in preparing these guidelines presumably because its recommendations do not support powerful vested interests in maintaining the status quo. (http://www.pulsetoday.co.uk/british-pain-society-president-ousted-after-row-over-nice-guidelines/11010745.article)

So what is the role of EBM when there is a question to be answered and but when a powerful establishment disagrees and disregards the findings?  EBM is portrayed as an empirical, reasoned and unbiased process, however as a construct, it falters in a real world situation where society, culture and illness interact to influence just what evidence based practice looks like.

In reply to Moira Kelly

Re: AGAINST

by Deleted user -

Moira, I think that medicine needs evidence.  In the past, doctors didn't always have access to the latest medical research. They often used to decide how to treat patients using only their own judgement and experience, and what they learnt at medical school. We now know that this is not the best way to practise medicine. This is because what doctors think is best for a patient is not always what is best when you actually look at the research. When researchers study a disease or a condition, they look at many more patients than a doctor will ever treat. Also, medical knowledge changes all the time. And what doctors used to think was the best thing to do, even a few years ago, might actually be considered harmful today. For example, many children used to have their tonsils removed to stop them from getting throat infections. The operation is rare now, because the risk of complications from surgery makes it likely to do more harm than good.

Only by looking at all the evidence and judging it fairly can you work out what the research really says about a treatment. Best Health is based on information from Clinical Evidence, a publication for doctors written by experts from all over the world. These experts look at all the evidence for a treatment. They weigh it up carefully and decide which treatments work and which don't work. They include research studies that have been published and those that haven't been published.

http://besthealth.bmj.com/x/static/514524/decision-support.htmlvvvv

In reply to Sultana Azam

Re: AGAINST

by Shivani Patel -

I agree with Sultana, I am in a way against EBM, I think trials and research can be manipulated in many ways by external forces, thus are not always best for patients. 

I also think that patients cannot be treated by strict rules and guidelines, as patients are all unique individuals, so cannot be treated the same. This is where the social determinants of health link in and a balance between these psychosocial factors and EBM needs to be struck. 

I also think EBM links in with 'deprofessionalism' and allows the removal of clinical judgement and instead dictates how medicine should be practised, undermining the role of the clinician. 

Of course it improves safety and quality of care, especially in the context of newly qualified health proffesionals, and I am glad when I qualify I can refer to protocols and guidelines. 

But I think as doctors become more experienced, and know what their patients need and have experience of what works best on different types of patients according to culture, social circumstances etc, this knowledge is in some cases more valuable than EBM. 

In reply to Shivani Patel

Re: AGAINST

by Moira Kelly -

Some very interesting points.  I made a note in the 'for' thread about context and I think its relevant here too.  

You are raising important issues about the relevance of institutional and wider social contexts (e.g. social inequality) to how evidence gets applied.  

This should link to issues you've covered in the health systems course.   

In reply to Sultana Azam

Re: AGAINST

by Deleted user -

I think with all EBM, it is important to think about context. It is all well and good giving a patient a drug because the papaers say so, but if that drug won't be beneficial for that patient as they have to come regularly to get it or travel far, then it may the best drug but it isn't the best drug for that patient!

 

publisher bias is an interesting point by Sultana. Its true that people won't want to read Descriptions of failed trials or ones that only affect few people so these wont be highlighted in the same way that others will... But this doesn't make them any less relevant? All need to be considered for a clinical decision.