Virtual Seminar: Topic 7 Reading Seminar Group 2

Thanks Nino, very helpful, but I am going to take a position against EBM being a panacea.

First off, the standard definition that you gave, is indeed widely quoted, but belongs to Dave Sackett (I only know this because he is also Canadian), from this article:

http://www.bmj.com/content/312/7023/71

Trish Greenhalgh and Anna Donald later wrote about how this definition was incontestable, therefore could not precise enough. They proposed this definition:

‘the use of mathematical estimates of the chance of benefit and the risk of harm, derived from high-quality research on population samples, to inform clinical decision-making’ 

(http://qmplus.qmul.ac.uk/pluginfile.php/158620/mod_book/chapter/3337/JPHCGuestEditorialGreenhalghJune2012.pdf)

This is more accurate, especially because it implies that the evidence may not always be of high quality, and that it can inform or guide practice, but is often insufficient to do so without clinical judgment.

In my opinion, clinical judgment should always supersede a EMB guidelines: If I am seeing a heroin addict for the first time in 3 years, the guidelines say that I should offer a pap smear, but my gut feeling says that I should rather just sit with her, and listen. I don’t think I could find high quality evidence for this, so I challenge any EBM purist to challenge this!

Although I understand the rationale behind EBM, I think it’s role in decision-making in the clinical environment needs further clarification as being a set of guidelines to inform current best practice based on evidence, as opposed to a set of rules that undermine the expertise of the doctor.

Medical knowledge is always expanding and evolving and I think EBM creates a platform to share this and creates a necessary level playing field for the standard of care. If doctors were left to their own devices ALL the time without a system of appraising things, progress would be slow if any was made at all.

All that said, and drawing on Moira’s comment about the impact EBM could have on the doctor patient relationship, of course there will always be outliers to any given ‘rule’, so I think it boils down to how the doctor is able to use their clinical judgment (which they have spent years training and perfecting), to strike a balance & incorporate the guidelines whilst still maintaining an amicable ‘doctor-patient’ relationship. Patients don’t want to be seen as just another number in the system after all, they want to be listened to and treated with a certain level of individuality. I believe this comes with experience, and although it may be a shock to the system of the current generation of older doctors who are used to doing things a certain way with much more autonomy, as it is being incorporated into our training as medical students, we are perhaps becoming more familiar with guidelines as well as the more psychosocial aspects of clinical care, and so it may become easier to strike this balance.

So, yes I believe strongly that medicine needs evidence based on high quality research in order to keep things moving forward as a whole. When it boils down to individual clinical scenarios that deviate from the norm however, I think doctors discretion and clinical judgement needs to be fairly weighted.

Hello all, I agree with all the points here – a great read.

“When confronted with an individual patient it is often hard to determine just who fits where. Surely a 25-year-old well-fed Asian college student who does not drink alcohol and who develops pneumonia is not legitimately placed in the same group as a 20-year-old white unemployed person who drinks heavily and whose nutritional intake is inadequate. EBM perforce is based on averages with the inescapable Mrs. Smith who may not fall into the Gaussian curve.”

The above passage is from a paper entitled Ethics and Evidence-Based Medicine: Is There a Conflict?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2100103/

I disagree.  Yes, patients differ in age, disease, and a plethora of other pathophysiologic factors (not to mention socioeconomic status).  And yes, EBM is often derived from a large cohort of people in a RCT and, therefore, cannot simply be applied to all individual patients.  But, ultimately, EBM is merely a list of protocols to guide clinical practice.  They were not designed to straightjacket the physician or to take the person out the patient – EBM serves as guidelines for which the physician can follow in supplementing vital experience and clinical judgment.  In my limited clinical experience, I find physicians that allow patient management to become a routine often succeed in treating the patient, but not the person.  A physician that first and foremost stamps his personality on patient management however, before following the EBM protocol, seems to fare better in the holistic management of the patient.

In reference to the above extract, a physician that mindlessly follows the EBM protocol failing to recognise the striking differences between the two men is, quite simply, not worth his salt.