Transcript What I want to talk about

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
• All evidence is sought and
examined systematically
• Evidence is wherever possible
quantified
• Evidence is considered in All
decisions 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
Has EBP changed the world?
• 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:
• New world:
Main information
Essential to
sources are
have immediate
experts,
(electronic)
selected
access to
journals, and
systematically
books
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
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