Evidence based medicine: a movement in crisis?

Posted on 10th July 2014 by Rich Thorley

Is a movement with a 20 year history now in crisis? It’s probably not what you’d expect to hear on Students 4 Best Evidence (S4BE), but that is what Trisha Greenhalgh and colleagues purport in their BMJ article published last month.[1] They have identified five problems that they believe are holding evidence-based medicine (EBM) back, but fortunately also provide solutions to these issues. The article follows another in the BMJ by Des Spence published in March entitled “Evidence based medicine is broken“, which Alice blogged about for S4BE.

First of all…

…they feel that the drug and devices companies are too intimately involved in research; they are distorting the evidence so that health is redefined as disease, and small differences between treatments are exaggerated by overpowered studies.

Secondly…

…they believe that while the vast volume of evidence available is a mark of the EBM movement’s success, it has now become unmanageable: “One 2005 audit [2] of a 24 hour medical take in an acute hospital, for example, included 18 patients with 44 diagnoses and identified 3679 pages of national guidelines (an estimated 122 hours of reading) relevant to their immediate care.”

Thirdly…

…Greenhalgh and colleagues say that trials are now focussed on discovering marginal differences between treatments, as the days of finding new treatments providing massive improvements in outcomes are over.

In their fourth point…

…they argue that the advent of EBM has meant that doctors are now all too ready to follow rigid algorithms, rather than adapting care to suit individual patients (shared decision making).

Finally…

…they point out that with an ageing population, and resulting increase in patients with multiple comorbidities, the one-size-fits-all approach with evidence targeted to a single condition and treatment option is becoming largely irrelevant.

So how do we get the EBM back on track?

The authors call for the individualised application of evidence to patients, with clinicians less reliant on following guidelines no matter what. This means returning to the original definition of EBM; the application of evidence to patient value is what separates EBM from critical appraisal.[3] They also say that research must be clinically relevant, and that journal editors have a responsibility to ensure that published material can actually be used by doctors. Last but not least, Greenhalgh and colleagues say that more independently funded research free from conflicting interests is required, and that research must be “broader [and] more imaginative”.

The article correctly calls for a refocusing of EBM’s direction. Having celebrated its 20th birthday last year, it is vital that the great strides made by the movement over that time (which are recognised and praised in this article) are built upon. Although “crisis” is perhaps a strong term, it’s probably fair to say that with the continuing problem of publication bias in addition to these five issues identified by Greenhalgh and colleagues, EBM still has a long way to go.

To read the full article go to:

http://www.bmj.com/content/348/bmj.g3725.

References:

1 Greenhalgh T, Howick J, Maskery N. Evidence based medicine: a movement in crisis? BMJ 2014;348:g3725.

2 Allen D, Harkins K. Too much guidance? Lancet 2005;365:1768.

3 Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71.

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