How would you fix evidence based medicine?
Medical students’ solutions on the way forward
Established more than 20 years ago, the evidence based medicine (EBM) movement is now in crisis. Born out of the uncertainty around the effectiveness of some treatments, it was an attempt to harness the immense amount of clinical scientific knowledge available and apply it in clinical practice to increase the safety, efficiency, and effectiveness of healthcare. In moving away from anecdotally and theoretically driven paradigms (traditional medicine) towards models of clinical practice that integrate high quality evidence, clinical judgment, and patient values, EBM was seen as the future of healthcare.
Although it was met with a fair amount of criticism, EBM has undoubtedly saved lives. A good example is that of flecainide, an early antiarrhythmic drug. Initially its mechanism of action seemed plausible: when a patient has an arrhythmia, a drug designed to stop that irregular rhythm should be therapeutic. This reasoning turned out to be perhaps the worst mistake made in Western medicine, purportedly killing more people in the United States than were killed in the Vietnam war. A subsequent clinical trial (Cardiac Arrhythmia Suppression Trial) that looked at the effectiveness of these drugs was stopped early because it showed that they increased the risk of death from arrhythmia, and the emphasis on the value of evidence from clinical trials led to the removal of these drugs from the marketplace.
Despite its many successes, the medical community has found itself in crisis with EBM. In 2014, Greenhalgh and colleagues published an article in The BMJ outlining why EBM has fallen into crisis and gave several reasons why this has happened. These included: the misuse of the “evidence brand” (that is, what good evidence is); the high rate of evidence and guideline publication that makes it impossible to stay practically up to date; too much reliance on automated decision support tools or flowcharts, which makes clinical consultations less personal; and limited ability to apply evidence and guidance for a single condition to patients with multimorbidity.
These are some of the contemporary challenges of EBM, whose solutions will require collective, collaborative, and interdisciplinary thinking. In preparation for Evidence Live 2015, a biannual conference on EBM hosted jointly by The BMJ and the Centre for Evidence-based Medicine (Oxford), we wanted to hear from the future leaders and shapers of EBM. We asked medical students and junior doctors to submit responses to the following question: “What is the most important intervention, change, or idea required to ‘fix’ evidence based medicine over the next 10 years, and how should it be implemented?”
Of the submissions we received, four stood out as particularly insightful and innovative, and are presented here. We look forward to an active discussion about these ideas at the Evidence Live 2015 student session on 14 April at Oxford University and hope they spark innovative solutions for the future of EBM.
Winners of Evidence Live 2015 competition: “What is the most important intervention, change, or idea required to ‘fix’ evidence based medicine over the next 10 years, and how should it be implemented?”
Change how evidence based medicine is taught and practised at medical school
Katherine Stagg, fifth year medical student, University of Oxford
Effective practice of evidence based medicine requires the critical appraisal of research to drive clinical decision making. The teaching of evidence based medicine has expanded greatly over the past decade to supply medical students and doctors with the necessary skills to carry out evidence based medicine. However, although it is recognised that evidence based medicine needs to be applied in day to day practice, this need is not reflected in most medical school teaching programmes, which leave students without a true grasp of how to use evidence based medicine throughout their careers. If the practice of evidence based medicine is to succeed over the next decade, then we must change how it is taught in medical schools.
Evidence based medicine is mostly taught in short courses in a classroom setting, often without showing how it should be used in clinical practice. How can evidence based medicine be used on ward rounds? How can it be used in multidisciplinary meetings? How can it be used on a daily basis? All of these questions relate to important aspects of the practice of evidence based medicine, but none of them can be answered without combining the teaching of evidence based medicine with daily clinical teaching. The integration of evidence based medicine across the medical curriculum would more accurately reflect how it should be used and encourage students to use it more often.[3 4]
How can we achieve this? Evidence based medicine has traditionally been seen as an academic topic and has been confined to the classroom, but with the appropriate training of facilitators it can be taught on ward rounds, in outpatient clinics, and at clinical meetings, as well as in the more traditional journal clubs. If this were done, when students became doctors they would already be able to use evidence based medicine effectively, bringing it into their daily decision making, rather than confining it to occasional academic meetings.
- 1. Del Mar C, Glaziou P, Mayer D. Teaching evidence based medicine. BMJ 2004;329:989.
- 2. Maggio L, Tannery NH, Chen HC, et al. Evidence based medicine training in undergraduate medical education: a review and critique of the literature published 2006-2011. Acad Med 2013;88:1022-8.
- 3. Ghojazadeh M, Hajebrahimi S, Azami-Aghdash S, et al. Medical students’ attitudes on and experiences with evidence-based medicine: a qualitative study. J Eval Clin Pract 2014; published online 16 Jul.
- 4. Ferwana M, Al Alwan I, Moamary MA, et al. Integration of evidence based medicine into the clinical years of a medical curriculum. J Fam Commun Med 2012;19:136-40.
- 5. Thangaratinam S, Barnfield G, Weinbrenner S, et al. Teaching trainers to incorporate evidence-based medicine (EBM) teaching in clinical practice: the EU-EBM project. BMC Med Educ 2009;9:59.
Empower patients with evidence through shared decision making
Ibrahim Sheriff, fifth year medical student, King’s College London
In the early 1990s, evidence based medicine replaced the traditional “theory and experience” approach to clinical practice, championing the systematic verification of the safety and efficacy of a new treatment or technique before its application. Although evidence based medicine has undoubtedly enabled progress, evidence is not always reflected in the actions of doctors and patients. Poor implementation of evidence by clinicians is often to blame; knowledge accumulates so quickly that facts learnt at medical school soon become obsolete, and doctors would need to read up to 20 scientific papers a day to keep up.
Nonetheless, we often forget that patients also play an important role in the implementation of evidence. Patients decide whether they adhere to therapeutic regimens, participate in screening programmes, or follow lifestyle recommendations. Therefore, as doctors we have a responsibility not just to know the evidence ourselves, but also to empower our patients to make evidence based decisions.
This can be a challenge, particularly in a “digital age” in which patients can look up medical advice online rather than visit their general practitioner or attend overflowing emergency departments. Furthermore, patients sometimes make decisions that we feel are “irrational.” However, rather than branding these patients “difficult cases,” we should listen to their concerns, share the evidence, and be prepared to compromise; anything less would go against the ethos of patient centred care.
Shared decision making is a possible solution; in essence, having a two way discussion with patients, weighing up the pros and cons of different options—both evidence based and non-evidence based—and reaching a mutually acceptable conclusion. This may be easier said than done in an increasingly strained health system. However, to benefit patients and to “fix” evidence based medicine, we must strive to find time for shared decision making amid the maelstrom of clinical practice.
- 1 Sackett DL. Evidence-based medicine. Semin Perinatol 1997;21:3-5.
- 2 Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225-30.
- 3 Shaneyfelt TM. Building bridges to quality. JAMA 2001;286:2600-1.
- 4 Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ 2014;348:g3725.
- 5 Barratt A. Evidence based medicine and shared decision making: the challenge of getting both evidence and preferences into health care. Patient Educ Couns 2008;73:407-12.
Think more about comorbidities of the 21st century patient
Kate Milne, fourth year medical student, University of Oxford
As a medical student embarking on clinical studies, when interpreting clinical trial data and attempting to apply them to patients I have found it difficult to understand how the conclusions of a trial, based on a select population, are relevant to my own patients. The complex comorbidities and associated polypharmacy of many 21st century patients distance them from trial participants, and therefore from the results obtained. Epidemiological studies have found a strong association between multimorbidity and age, so as the United Kingdom’s population continues to age, with the number of people over 60 expected to double by 2050, will the external validity of research be further compromised?
Currently, older patients and those with complex problems are not included in the research on which clinical practice is based. A systematic review by Van Spall and colleagues found that randomised controlled trials published in major medical journals did not always report the exclusion criteria used, but that women, children, older people, and those with common chronic medical conditions were often excluded. Arguably this will have been to ensure patient safety, but such a selective approach can result in doctors making incorrect generalisations in their practice. For example, the results of the Randomized Aldactone Evaluation (RALES) trial influenced the prescription of treatment for heart failure, and the subsequent use of the combination of spironolactone and angiotensin converting enzyme inhibitors inadvertently increased the rates of morbidity associated with hyperkalaemia. The trial’s failure to detect this effect is attributed to the groups that were excluded.[3 4]
In my eyes the solution to this problem is twofold. Firstly, the patient selection criteria of current and future trials need to be reviewed to ensure that the results are relevant. Secondly, the approach to the teaching of evidence based medicine for medical students needs to change, with emphasis being placed on teaching future doctors how to use trial data with reference to complex and realistic cases, so that they can carry evidence based medicine into clinical practice.
- 1 Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012;380:37-43.
- 2 Cracknell R. The ageing population. 2010. www.parliament.uk/business/publications/research/key-issues-for-the-new-parliament/value-for-money-in-public-services/the-ageing-population/.
- 3 Van Spall HG, Toren A, Kiss A, et al. Eligibility criteria of randomized controlled trials published in high-impact general medical journals: a systematic sampling review. JAMA 2007;297:1233-40.
- 4 Juurlink DN, Mamdani MM, Lee DS, et al. Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. N Engl J Med 2004;351:543-51.
- 5 Greenhalgh T, Howick J, Maskrey N, et al. Evidence based medicine: a movement in crisis? BMJ 2014;348:g3725.
Encourage junior doctors to speak up to change evidence based practice
Aaron Dale, second year graduate entry medical student, University of Oxford
When I entered medicine as a postdoctoral researcher I looked forward to applying my scientific training to clinical problems. As part of my course I recently attended a workshop on evidence based surgical practice where we discussed two landmark papers from prominent journals. Although both had faults in their methodology, sober analysis of the data strongly indicated that for two common procedures the option of “no surgery” was deemed to be no worse than the current surgical intervention. When the presenting consultants were asked, in light of these findings, would they still operate, all present said that they would. This was not challenged further.
It has been proposed that evidence based medicine is a movement in crisis. Reasons for serious concern include bias in the available evidence and a tendency to apply evidence at a population level, at the expense of patient oriented care.[1 2] I propose that the biggest challenge faced by evidence based medicine is a cultural one—that of the medical hierarchy. The practice of medicine is still based on steep authority gradients, which makes it difficult to challenge the opinions and actions of much more senior professionals, a situation that has been proposed to be a major contributor to preventable medical errors. My assertion is that the medical hierarchy also limits the ability of students and junior doctors to challenge their seniors and prevents an open, collaborative, and reflective scrutiny of the evidence base for current practice.
To change this we should take lessons on cultural resculpting from the Mid Staffs inquiry. A key recommendation of the Francis report was to move away from a defensive, introspective culture that placed responsibility for care at the top of the medical “totem pole,” and left those further down the hierarchy feeling unable to raise concerns. One way this has been achieved in practice is through the implementation of monthly meetings where observations of care within the trust are discussed in an open forum by any healthcare worker, regardless of seniority. Regular meetings of this kind with the emphasis on evidence may empower junior healthcare workers to challenge whether the evidence base for our current interventions is adequate.
- 1. Chalmers I, Glasziou P, Godlee F. All trials must be registered and the results published. BMJ 2013;346:f105.
- 2. Greenhalgh T, Howick J, Maskrey N, et al. Evidence based medicine: a movement in crisis? BMJ 2014;348:g3725.
- 3. Cosby KS, Croskerry P. Profiles in patient safety: authority gradients in medical error. Acad Emerg Med 2004;11:1341-5.
- 4. Francis R. Lessons from Stafford. Med Leg J 2013;81:153-65.
1Department of Primary Care Health Science, University of Oxford, Oxford, UK, 2Cumming School of Medicine, University of Calgary, Canada
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
- More T. Deadly medicine: why tens of thousands of heart patients died in America’s worst drug disaster. Simon & Schuster, 1995.
- Cardiac Arrhythmia Suppression Trial (CAST) Investigators. Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. N Engl J Med 1989;321:406-12.
- Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis? BMJ 2014;348:g3725.
Cite this as: Student BMJ 2015;23:h1522