A story from a little country far far away: thoughts on EBM
Posted on 22nd April 2013 by Donatas Zailskas
So here I am, sitting behind my desk at home writing this blog post that‘s supposed to be about evidence-based medicine (EBM) and I realize that I should probably introduce you to my country first – that way the things I‘m about to tell you will better fall into place. I am from Lithuania– one of the three small Baltic countries, located near the Baltic Sea. Chances are you have never heard of it and if you have, you might have mistakenly assumed that we‘re a part of Russia – we‘re not, don‘t ever do that. Even though we signed our Act of Independence on 1918, February 16th, we were under the oppression of The Soviet Union from the 1940s up until 1990, March 11th– the day we restored our independence. The oppression left the country with a post-traumatic stress disorder and quite a few people suffering from Stockholm syndrome, so to speak. But we were good and tried to be compliant: we took our medicines, started a therapy and now we are just starting to get it, starting to talk about it. We‘d like to say we are healthy, but we‘re not quite there yet and we’re too proud to admit otherwise. I was too young to remember all that struggle and now I only encounter the aftermath. Yet here I am, a 6th year medical student trying to make sense of it.
You might wonder how all this is connected to EBM. Well, it‘s difficult to describe the current state of healthcare here, and eventually I will be biased trying to do that, but bear with me. EBM itself is a young field, but it‘s even younger in Lithuania. That pattern I mentioned in the first paragraph? It is mirrored in the medical community, too. We‘d like to say that EBM is practiced the way it should be but we‘re not quite there yet and we‘re too proud to admit otherwise. The impact of oppression left a mark on people‘s mentality, especially in the older generation. Authority here remains a huge influence, so is the lack of trust in a lot of new implemented changes, evidence being one of the main examples, and anecdotes quite often inform clinical decisions. Don’t get me wrong, we have some truly magnificent researchers, great physicians and teachers, but something is missing and something does not feel right. I cannot really say that there is a lack of evidence-based practice, no, more like there‘s a large insufficiency of general understanding of what evidence really means and why it is so important. I am a child of evidence based medicine: I grow with it, I try to learn it’s principles and slowly accustom myself to the way I should practice medicine in the future. The sad part is I have to do it by myself and I am not the only one. I see this as one of the main issues in student education: if young doctors are not taught about EBM, how are they supposed to provide the best possible patient care in the future? How can they approach the literature critically enough? How can they avoid quackery, pseudoscience and bad science in general? Me, my friends, our younger colleagues – we are willing and able, but we can only do so much without a proper education on EBM in due time. I could count on my fingers the number of lectures dedicated to EBM that we had to attend. There is no curriculum that teaches evidence-based medicine, we barely hear these three words throughout our studies. Of course, it does not mean that we‘re being taught wrong things – it‘s just that we don‘t have that comforting sense of security that we‘re being taught the right things (and occasional lecture slides with things like “Homeopathy” in them certainly do not reinforce our trust). The lack of proper EBM program is an issue of great importance not only because of inadequate medical knowledge. Medical students tend to develop bad habits as they go through their study years unless they are put into place by good examples, hopefully, their teachers. Sadly, we see a lot of bad habits among our peers ranging from bad practices and research misconducts to ignorance and just plain disbelief in the evidence. This is troubling. Even though EBM is a blossoming field, it has already made a huge impact on the world health that could hardly be discounted. And it‘s still going, developing, improving itself as it is being used by doctors and scientists all around the world. Every research we do, every critique we provide, every patient we survey makes an impact, because it all boils down to one huge pile of information gathered in a systematic way that everyone can use. We are one in the fullest sense, so this type of reckless student behavior saddens me and my colleagues to the extent where we realize that some sort of radical change is needed.
This brings me to my next point: a recent conference on evidence-based medicine. I‘m not going to lie – this was like Christmas to me, and by now you might understand why. To actually be with other fellow students who are interested in the same thing as you are, who are worried about the same problems or even with those who just want to deepen their knowledge in EBM was a great experience. The event was organized by two Lithuanians – Dr. Karolis Bauža and Tumas Beinortas – studying in Oxford Medical School, who share the same concerns about the future of healthcare in Lithuania. It was because of them we had the pleasure of listening to two special guests, Dr. Kamal Mahtani and Dr. Jeremy Howick from the Center of Evidence Based Medicine in Oxford alongside with one of our own – professor Rūta Nadišauskienė who, if I may say so, could be called the EBM pioneer of our country. Well, at least student-wise: she was the first person to actually dedicate a separate lecture on EBM to medical students. Sadly, that was already the 5th year. Better late than never?
The plenary session started with an introductory word and was followed by Dr. Jeremy Howick‘s lecture “The Philosophy of Evidence-Based Medicine and the Levels of Evidence”. Dr. Howick, author of the book “The Philosophy of Evidence-Based Medicine” (1), has spent the last 10 years investigating the rules of evidence and in this lecture he argued that before EBM medicine was often based on expert judgment and mechanistic reasoning and now is based (or, at least, should be based) on evidence of systematic reviews and controlled studies. Dr. Howick talked about the levels of evidence, flaws and damage that expert judgment and mechanistic reasoning deliver providing such examples as “Baby and Child Care” (2) by Dr. Benjamin Spock and “The sins of expertness and a proposal for redemption” (3) by David Sackett. Then he compared observational studies and RCTs, talked about some principles of randomization and noted how observational studies tend to overestimate the effects of treatments and be more biased as compared to RCTs. However, he pointed out that RCTs are not always necessary, citing the famous BMJ article “Parachute use to prevent death and major trauma related to gravitational challenge: systemic review of randomized controlled trials” (4), it‘s just that testing treatments is crucial, because, to quote Dr. Howick, “…everyone thinks their treatment is like a parachute.”. The day was off to a good start. After a brief exchange of questions from the audience, next up was Dr. Kamal.
Dr. Kamal, who is a general practitioner in Oxfordshire as well as an honorary fellow at the Centre for Evidence Based Medicine, spoke about how EBM improves medicine and how it impacts daily practice. He began with a Flecainide story, an anti-arrhythmic drug that, due to faulty rationale behind its use, was widely prescribed as an effective measure reducing mortality in post-MI patients. By 1989 there had been over 200 000 people treated with Flecainide post-MI, however, the CAST study (5), initiated 10 years later showed a horrible turn of events: Flecainide was not actually reducing the mortality, but increasing it. We were asked to reflect on how much of what we practice is based on mechanistic reasoning and how much of it is based on actual evidence. Unfortunately, silent disappointment ensued; too much. Dr. Kamal continued with a next drug called Rosiglitazone, announced as a major breakthrough in treating type 2 diabetes (6). The truth is, in medicine, rarely do such marvelous treatments exist, and Rosiglitazone was surely not one of them – the following studies revealed an increased risk of heart attack, and in 2010 it was recommended to take Rosiglitazone off the market. This was to show us the importance to critically appraise a study despite the significance or the impact factor of the journal. Dr. Kamal finished off with a personal story about an encounter with a breathing device promoted to his patients as a method of reducing blood pressure. It was all over the news – as fantastic unconventional treatment methods usually are – but, the evidence had been scarce and there had been no systematic reviews. So Dr. Kamal and colleagues decided to do one (7) and found, unsurprisingly, no overall effect improving patient care. All these stories were told to justify three crucial points made by Dr. Kamal at the beginning: without EBM, money will be wasted, patients will suffer or they will die. It’s as simple as that.
After a long awaited lunch break we rushed back for our last lecture: “EBM in Lithuania”. Professor R.Nadišauskienė, who is the head of OB/GYN clinic, has been giving lectures on EBM for over 10 years. She was very happy to see a lot of her students in the audience and – for all the grateful nostalgic reasons – we were happy to see her as well. Every year she asks her students if they have previously heard about EBM in other specialties, but very few answer that they have, and this coincides with a lot of problems I mentioned previously. Coming back to the conference, the professor covered a number of topics: from Archie Cochrane and levels of evidence to the slowly growing EBM practice in various different fields in Lithuania, and her message was simple: EBM is the appraisal of the best available evidence, and we still have a lot of work to do in Lithuania. In addition to that, there was one moment in the conference that, to me, was the most significant. It was prompted by Dr. Howick’s question about the state of EBM in other specialties. There is no need to assure us of the level of EBM in OB/GYN – it is top notch. Unfortunately, this is not always the case elsewhere – professor Nadišauskienė knew that, smiled, joked about a need to stay polite, and we all understood the situation. She referred the question to a friend, a professor of rheumatology that I was not familiar with. What she said described perfectly what me and my friends had been seeing every day, and I’m paraphrasing: we attend local conferences and we have to trust that the information provided is already evidence-based, we have no other choice, we do not know and we work with what we’ve got. Her words were so honest that we couldn’t feel anything but respect for this doctor who not only recognized the imperfections of the system, but was bold enough to express these concerns out loud. I‘m just a student, I have neither the authority, nor the knowledge to be talking about these kind of things so you can dismiss everything I said, but do take her words for granted.
The event was finished with a workshop where we were taught how to search for articles, how to critically appraise the literature, how to form a clinical question and so on, but, most importantly, it was a place where we got to communicate, discuss and learned a lot without even noticing it. If after this wall of text you are left wondering “Did you not know all this??” – and I can only speak for myself and some of my friends – we did. All this was not unknown – but this event was just that previously mentioned good example that put us into our places and gave us hope about the future. As cliché as it sounds, the first step in solving a problem is recognizing there is one. We have a problem. So here I am, a 6th year medical student trying to make sense of it.
1. Wiley: The Philosophy of Evidence-based Medicine – Jeremy H. Howick [Internet]. [cited 2013 Apr 20]. Available from: http://eu.wiley.com/WileyCDA/WileyTitle/productCd-140519667X.html
2. Dr. Spock’s Baby and Child Care [Internet]. [cited 2013 Apr 20]. Available from: http://books.google.lt/books/about/Dr_Spock_s_Baby_and_Child_Care.html?id=IDnk1fYa47oC&redir_esc=y
3. Sackett DL. The sins of expertness and a proposal for redemption. BMJ [Internet]. 2000 May 6 [cited 2013 Apr 20];320(7244):1283–1283. Available from: http://www.bmj.com/content/320/7244/1283.1
4. Smith GCS, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ British Medical Journal [Internet]. BMJ Publishing Group Ltd.; 2003;327(7429):1459–61. Available from: http://eprints.gla.ac.uk/22221/
5. Fox M, Lipton HL. The new england journal of medicine. The New England Journal of Medicine [Internet]. Massachusetts Medical Society; 2011;343(1):607–8. Available from: http://www.nejm.org/doi/abs/10.1056/NEJM192802231980115
6. Gerstein HC, Yusuf S, Bosch J, Pogue J, Sheridan P, Dinccag N, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomised controlled trial. Lancet [Internet]. 2006 Sep 23 [cited 2013 Mar 9];368(9541):1096–105. Available from: http://www.thelancet.com/journals/a/article/PIIS0140-6736%2806%2969420-8/fulltext
7. Mahtani KR, Nunan D, Heneghan CJ. Device-guided breathing exercises in the control of human blood pressure: systematic review and meta-analysis. Journal of hypertension [Internet]. 2012 May [cited 2013 Apr 20];30(5):852–60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22495126