Make Evidence-Based Medicine Great Again!

Cristina Roure
 

“Make Evidence-Based Medicine Great Again!” is the provocative title of a conference that Dr. Domenico Pagano delivered at the 56th Congress of the American Society for Cardio-thoracic Surgery, calling for the need to restore professionalism, integrity, and trust in data and evidence in medicine. The conference is long, it lasts 55 minutes, but Pagano makes a brilliant presentation on the increasing manipulation that has led us to the swamp in which evidence-based medicine (EBM) currently inhabits.

Modern clinical management: the basics

In recent decades, clinical management has had a couple of conceptual disruptions that have generated interest in the welfare act as an object of study. The first was when, in the early 90s a group of epidemiologists moved clinical epidemiology from the academy to the consultation and developed evidence-based medicine; and the second came when governments and health professionals became knowledgeable about the clinical work’s ability to do harm. The "To err is human" from the Institute of Medicine report in late 1999 was the turning point of patient safety programs. Now, in the second decade of the century, starting from those two fundaments (security and evidence), all the interest is in knowing what is the value that clinical practice brings to the health of people.

The conceptual foundations of modern clinical management

Last century belonged to the doctor, this one should belong to the patient

RT @gesclinvarela Historia oral de la Práctica Basada en la Evidencia #PBE http://t.co/jXEyQ4o3o8

— X.M. Meijome (@EnferEvidente) julio 6, 2014 

This twitter account, @enferevidente, specializing in clinical safety, has offered us the link to a paper on the history of the EBM which is a jewel in itself. If you click on the tweet, you may access a collaboratively edited video from the British Medical Journal and The JAMA Network. It’s a chat, moderated by Richard Smith, where Gordon Guyatt, Kay Dickersin, Drummond Rennie, Brian Haynes and Paul Glasziou – all ‘parents’ of EBM. There are also connections with David Sakkett, Iain Chalmers and Muir Gray. If you wish to press the play button (do it through the link in the tweet), you will see how veteran scientists explain their conversion to the, new (at that time) way of seeing clinical research, along with their views on the current circumstances.

The future of EBM from its "parents"

What interested me most, however, was the last round of the chat, when Richard Smith questions the guests about how they see the future of EBM and clinical practice, and on this I made some notes as follows:

Knowledge chain sanitation, a difficult undertaking

By Cristina Roure 

In one of my posts  from "Pantone" series, August 17, I was talking of the need for crystal clear knowledge sources so we can make appropriate decisions, but the point is that our sources are contaminated by a number of biases that permeate the decisions we make as citizens, as patients, as health professionals or managers, and this leads to over diagnosis and overtreatment. Faced with these biases, Gerd Gigerenzer and Muir Gray, in the book "Better Doctors, Better Patients, Better Decisions" propose some sanitization measures, to which I have allowed myself to add some homemade ones:

1. How to make research more relevant to patients

a) Regulatory agencies, such as the FDA or the EMA, should require studies demonstrating the superiority of the new drugs compared to the best treatments available, not placebo.
b) Independent sponsors should promote research on simple, beneficial and patient relevant treatments and practices that do not involve the use of drugs or technology, practices that for this reason lack sponsorship (exercise, healthy diets or checklists to improve clinical safety).
c) I would add that the so called Patient Reported Outcomes should be included in clinical trials, which unlike conventionally employed variables, report on the effectiveness of treatment perceived by the patient.

Crystal clear knowledge for decision making

By Cristina Roure 

Excellent health care is one in which patients, professionals and managers apply the best available knowledge in decision making. Only well-informed agents can take the most appropriate decisions for an effective, safe and efficient health system. We often think that the big problem of the system is the lack of money, and only devoting more resources will solve the problems, but lack of knowledge is much more worrying than it may seem at first glance.

Sir Muir Gray, Chief Knowledge Officer of the National Health Service (NHS), uses an analogy that I find very spot on: "It takes knowledge as crystal clear as the water we drink if we want to take the right decisions." But the current reality is very different because we drink from contaminated sources of knowledge.