As a nurse in the nineties, training as a doctor in the noughties, Evidence Based Medicine (EBM) was my truth. I was a believer that we should follow the processes and guidelines that flowed from research and our analysis of data. I felt that the statisticians and researchers, knew more than myself, with their T Values and Confidence Intervals and were experts, building standards from which the foundations of policy and guidance emerged. These made us feel safe and we were part of a community that shared a common understanding.
I now recognise how EBM underpins my feeling that I face complexity every day.
We have built ourselves fixed mindsets and rabbit holes which have trapped us. People and systems do not fit into these boundaries. When we describe complexity, we are describing the feeling of panic when something does not fit this paradigm and when our decisions are outside this norm and creates a fear of rejection.
These publications give insight and I would highly recommend a read to gain a feel for the paradox of EBM and I love the story of The Emperors Clothes.
The Emperor’s New Clothes: a Critical Appraisal of Evidence-based Medicine – PMC (nih.gov)
Evidence based medicine: a movement in crisis? (ox.ac.uk)
The following blogs will review this interesting topic
- Bias in EBM
- The Challenges of EBM
- Lies, Damned Lies and Statistics
- Personalised Medicine, Artificial Intelligence and EBM
- Justice In Healthcare
- Understanding Power, Complexity, and Influence
Evidence-based medicine (EBM) emerged as a ‘new paradigm’ for improving patient care. Yet there is currently little evidence that EBM has achieved its aim.
EBM is defined as the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.
EBM become popular, due to the need for patient safety, inconsistencies in clinical decision-making and to control escalating costs, although the science of ‘best research evidence’ has paid less attention on how to capture the subjectivity, uniqueness, and real-world messiness of individuals.
The question of what might constitutes ‘best evidence’ is addressed in levels of evidence tables such as the one produced by the Oxford Centre for Evidence-Based Medicine.
Like most other evidence-ranking schemes, systematic reviews of randomized trials are placed at the apex of the evidence pyramid with mechanistic reasoning and ‘expert opinion’ ranked at the bottom. The flaws in analysis ignores outliers and the biases of research have potentially created real harm.
Qualitative research that describes the patient experience, including the perspective of carers and significant others, can add granularity and meaning to research findings. Nevertheless, this is viewed as less robust than quantitative evidence, rather than complementary to it and addressing different questions.
The individual case report sits at the bottom of EBM’s hierarchy of evidence and we are asked to discount anecdotal findings. This might be appropriate however, the outlier, provides a real opportunity for insight and for individualised management plans.
In a world of only biochemical processes and reactions, EBM may be the answer however our chemistry is contained within a living person, who may experience poverty, disadvantage or be struggling to cope with life. Trying to create simplicity out of huge complexity is a mistake.
Literature evidence has then been collected into “guidelines” for a specific clinical situation. I am sure, they are valuable instruments, however, they have become unchallengeable, and the “absolute” truth. They constantly increase in number, cover virtually every aspect of medicine and restrict the “freedom” of healthcare staff. We are gradually becoming passive executors of someone else’s decisions and have lost the skills to apply judgement, with people fearful of making mistakes in a black and white world rather than being confident with risk and uncertainty.
If EBM were the revolution it aspired to be, we would expect population-level health gains, such as those that occurred after the introduction of antibiotics, improved sanitation and smoking cessation. The Black Lives Matter Movement, covid outcomes and our knowledge of the social determinants of healthcare inequity teach us that disparity and disadvantage may have been amplified by EBM.
The current evidence about health care outcomes suggest that the cost of health care continues to rise, improvements are plateauing, systemic disadvantage is embedded and trust in professionals decreasing.
The future of healthcare will challenge population focused EBM, through understanding our genetic code, our neural networks and the rise of personalised medicine. We need to find confidence in managing systems with artificial intelligence, algorithms and robotics changing the face of healthcare.
I am not suggesting that we throw away EBM and guidelines, but there are serious problems to consider.
The changing landscape of medicine will create a new environment:
- This must include valuing those with personal lived experience and being inclusive.
- Philosophy alongside science can help us consider a different lens to manage complexity.
- Alongside knowledge, systems and policies, we need to understand each other’s perspective and be able to develop ways of creating models of shared understanding.
Our teams need to think laterally, explore how we think ourselves, how we co-create meaning with others and how this manifests in a wider eco-system, going well beyond the rigidity of the EMB and other structured formats. Clearly, we need to preserve and guarantee the safety of our patients but to improve clinical outcomes, we need to have a shift in mindset away from EBM.
