Problems with EBM (actual post)

Problems with EBM (actual post)

by Lucy Caroline Eastgate -
Number of replies: 6

 So, it's been really interesting looking at how Evidence Based Medicine is often seen as the 'gold standard' and that much treatment today is based on the latest (or in some instances, not so new) research. The concept of EMB is great and as discussed in the 'benefits of EBM' posting, has brought about some wonderful changes. But it is worrying that there is a risk of use of EBM when the evidence base is not so strong, bias or is used solely in making decisions. One author has written that they have concerns about the way trials are often presented with an overwhelming arrogance as if they provided the truth, the whole truth and nothing but the truth about specific clinical questions. But it was pointed out that even the best trials never tell the whole truth.

So should we be concerned about the methods used for researching certain clinical issues? For example, Randomised Controlled Trials- frequently described as the best available, which even when randomised and controlled, will have specific inclusion and exclusion criteria.

One of the things we had spoken about before is how it takes individuality out of the care given to patients. There are two ways of looking at this- Firstly whether the findings of trials can be extrapolated to wider groups of patients not included in the trials. Secondly, as Trish had discussed her Afghan patient, when care pathways are designed as a result of Evidence Base, patients who need an individual response may find themselves being given standardised, possibly harmful, care.

I would like to leave this open for discussion and leave you with a couple of light hearted opinions of EBM as food for thought (taken from the website below)-

'The science that we push has money attached to it'

'much of the 'Evidence' today is doctored and fabricated by Big Pharma

'I see EMB as a way of 'dumbing down' medicine to allow NP's to try to practice medicine'

'EBM is a “cookbook”. One size fits all. Experience and years of training does not matter'

'EBM is the new religion'

Some more rational opinions from the same website-

'EBM should be used as a tool in the decision making process, but should not be deferred to in place of independent thinking nor considered a gold standard not to be deviated from.'

'EBM is a well-meaning and useful concept if tempered with judgment and judicious application. My challenge with it is that it has been turned into a religion, and we physicians are supposed to worship at its alter without the addition of any critical thinking.'



http://www.sciencebasedmedicine.org/index.php/how-do-you-feel-about-evidence-based-medicine/

'What is right and what is wrong about evidence based medicine? http://www.ncbi.nlm.nih.gov/pubmed/12950509

In reply to Lucy Caroline Eastgate

Re: Problems with EBM (actual post)

by Yasin Fatine -

I think it is all well and good to criticise where EBM falls short; you mentioned the quotes on how evidence is doctored and that it has money attached to it, but as a concept is it really that bad? Another quote claims that it is 'dumbing down' medicine, and that it is a 'cookbook', but is that necessarily the aim of EBM?

If a certain treatment or intervention is proven to improve outcomes in patients, then why wouldn't you use it? Yes, sometimes a doctor's intuition may override normal practice, which I think the system should cater for, but we need to look at how patient outcomes have improved as a result of the introduction of EBM, and maybe acknowledge it is alright to not follow the 'cookbook' too rigidly; guidelines, not rules.

In reply to Lucy Caroline Eastgate

Re: Problems with EBM (actual post)

by Storm Parker -

I'm going to go with Lucy on this one- yes EBM is great, but are clinicians too reliant on it? Rather than building up experience and putting the individual patient narrative first, doctors can whip open a handbook/webpage and find out the guidelines for treatment. Perhaps EBM is too dumbed down? Or worse, dumbing down our professionals?

Framing EBM as a social movement implies that it is not here to stay. It's good for now, but in future it may evolve into something that will encompass the individual narrative, rather than simply a generalised one-size-fits-all.

EBM is the best tool we currently have to decide what is best for patients, but as Andreas has said in the other thread there is a "lack of something else". We may be too reliant on EBM and therefore not open to potential future alternatives.

In reply to Storm Parker

Re: Problems with EBM (actual post)

by Deleted user -

No doubt EBM is a good tool in medicine but sometimes even external evidence may be insufficient or inapplicable for a particular patient, sometimes it goes beyond what is on the guidelines. Evidence can only inform but it takes some expertise to decide whether the external evidence applies to the case at hand. From recent CSDH report we have seen the role social determinant play in the health outcome of population. The clinician might have to connect with the social factors and link it with the biological factor. Evidence might lie outside the science and tend towards the social.Whatever tool is being used, better health for the patient should be the ultimate goal.If potential aternatives gives a better outcome then it should be embraced rather than focus on one approach 

In reply to Deleted user

Re: Problems with EBM (actual post)

by Sara Shaw -

What an interesting thread. You all suggest that some evidence is a good thing, but other things are also important. So, what is this thing called 'evidence' that you're referring to? What kind of evidence is - or isn't - most relevant? And where is the boundary is between evidence and judgement?

In reply to Sara Shaw

Re: Problems with EBM (actual post)

by Sandeep Suryadevara Rao -

I think 'evidence' refers to statistics for improved health outcomes in patients treated in a particular way. These improved health outcomes tend to need to be backed up my solid numerical data in order to be taken seriously.

Whatever this search for evidence is, it seems to be en Vogue. Not just in medicine. Any professional practicing anything seems to need some kind of statistic to prove their worth. It may be an osteopath who claims that 80% of people improve with the treatment they offer, or a seller on Ebay with 99% positive feedback. It stikes me that the numbers are important, and that seems to be why some people dont take qualitative work seriously.

In reply to Sandeep Suryadevara Rao

Re: Problems with EBM (actual post)

by Sara Shaw -

Great seminar this week, well done everyone!

And some really good 'for' and 'against' arguments. Interesting to see quite a bit of common ground..... posts on both sides of the debate highlighted the need for judgement and intuition in producing 'evidence' and in developing and using guidelines. Agree that there are problems with RCTs, industry funding and the emphasis on numbers!