Why do we need knowledge work? What about evidence based medicine?

How does evidence-based medicine fit in to the knowledge work framework?

If you went to medical school in most countries since around the 1990s the dominant paradigm, or way in which you were encouraged to view clinical medicine and your future job was called evidence based medicine. In fact the concept of ‘evidence based’ has been so popular it has now taken hold in all sorts of other fields like social or educational policy making. But what do we mean when we say evidence based?

Evidence-based medicine promotes a hierarchy of evidence with randomised controlled trials at the top and other scientific studies below. From this evidence you can provide grades of recommendation. It would be impossible to read all the evidence available so various bodies produce guidelines that aim to synthesise the evidence so GPs and other clinicians know what to prescribe.

So what is the problem?

A number of authors/commentators have asked is evidence based medicine meeting the challenges of medical care in the 21st century^1,2,3? There are several problems with the idea that “evidence based” always means right.

• Most clinical evidence remains a poor fit for understanding and managing complex multimorbidity and trial participants are not reflective of the population in general
• What provides benefits at the population level may be marginal for the individual involved.
• The volume of guidelines is unmanageable – no one doctor could manage to read and apply all applicable guidelines for every patient
• The description of “evidence based” can be used by pharmaceutical companies and others with vested interests within the healthcare system to encourage decisions and practices that may not always be in the patient’s best interests. The opoid crisis in America is an example of this.
• A focus on following algorithms and rules can disenfranchise individual clinicians making them fear censure if they make a decision that veers outside guideline or current practice territory, even if it is in the best interests of the patient.

This is not to say we should not use the best available clinical evidence. Of course we should. But as described by mindlines work, we need to recognise our role is to use the ‘evidence’ to INFORM our whole-person-based practice – but not allow it to dictate the care we offer. EBM recognises the need to judge how we apply evidence to the the individual patient. Our job is not just to apply guidelines but to generate new evidence in practice in context. The next article discusses complexity in healthcare and why simple protocol based care is unlikely to be successful.

References

1. Ioannidis JP. Evidence-based medicine has been hijacked: a report to David Sackett. J Clin Epidemiol. 2016 May;73:82-6. doi: 10.1016/j.jclinepi.2016.02.012. Epub 2016 Mar 2. PMID: 26934549.
2. Heneghan C, Mahtani KR, Goldacre B, Godlee F, Macdonald H, Jarvies D. Evidence based medicine manifesto for better healthcare. BMJ. 2017 Jun 20;357:j2973. doi: 10.1136/bmj.j2973. PMID: 28634227.
3. Tebala, G. D. (2018). The Emperor’s New Clothes: a Critical Appraisal of Evidence-based Medicine. International Journal of Medical Sciences, 15(12), 1397–1405. https://doi.org/10.7150/ijms.25869