evidence based practice (not medicine): perspectives of an editor richard smith editor, bmj

Evidence based practice (not medicine):

perspectives of an editor

Richard SmithEditor, 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


• 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


• 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


• 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


• 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


• 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


• 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


• 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?”


• 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


• 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


• 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


• Old world: Clinical skills are seen as semi-mystical

• New world: Clinical skills can be audited and managed


• Old world: Research is marginal to practice

• New world: Research and practice go together


• Old world: Analysis of research is haphazard

• New world: Analysis of research is systematic


• Old world: Not important to gather new evidence from patients routinely

• New world: Patients should be included in trials wherever possible


• Old world: Main information sources are experts, selected journals, and books

• New world: Essential to have immediate (electronic) access to systematically collected evidence


• Old world: Most of what doctors need to know is in their heads

• New world: Doctors must use information tools constantly


• Old world: Only lip service is paid to keeping up to date and learning new skills

• New world: Essential to keep learning new skills


• Old world: Most medical care is assumed to be beneficial

• New world: Widespread recognition that the balance between doing good and harm is fine


• Old world: Clinical performance is not systematically audited

• New world: Clinical performance is regularly reviewed and managed


• Old world: Managers have little involvement in clinical proceses

• New world: Managers are involved in clinical processes


• Old world: Organisational model is hierarchical

• New world: Organisational model is much more democratic, based on ability to use evidence


• Old world: Doctor patient relationship is essentially master/pupil

• New world: Patient partnership is the norm


• 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


• 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

evidence based practice (not medicine): perspectives of an editor richard smith editor, bmj

Documents

essence of evidence

possible quantified

radical making evidence

healthcare evidence

provisional slide

medical research slide

personal history reflections

result of medical care