July 2000 • Volume 6 • Number 7
What's all this ruckus about EBM?
BY CINDY McCANSE
Evidence-based medicine: What is it, and why should you care about it?
The definition established by the Subcommittee on Clinical Content of the Commission on Continuing Medical Education takes its cue from EBM guru David Sackett, professor and former director of the Centre for Evidence-Based Research, Oxford, England. The SCC definition blends Sackett's three basic EBM tenets -- research findings, clinical judgment and patient values -- with a fourth dimension:
See CME accreditation story. "Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. For family physicians, evidence-based medicine is also of value in making decisions about the care of families and communities."
The SCC definition adds that CME content is considered evidence-based if its recommendations "are labeled and presented with the highest levels of available evidence, according to an evidence-grading scheme accepted by the AAFP."
The SCC has devised a classification hierarchy as a starting point for assigning an "evidence value" to a given diagnostic or therapeutic recommendation. Four levels have been proposed, ranging from meta-analyses to expert consensus statements.
Promoting an evidence-based approach to patient care is not new to the Academy. The Home Study Self-Assessment® program devoted a monograph to the topic in February 1998, and a recent HSSA monograph on hypertension highlighted an evidence-grading system developed by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.
The Family-Centered Maternity Care course encourages prospective faculty to provide supporting evidence for their recommendations. And the Advanced Life Support in Obstetrics program is codifying a system for incorporating EBM into its provider curriculum.
But critics of EBM challenge the need to apply this methodology in all aspects of patient care. In a session on EBM at the May 3-7 Society of Teachers of Family Medicine annual spring conference in Lake Buena Vista, Fla., several attendees cited a paucity of time for critical review of available clinical evidence, as well as a lack of the statistical training necessary to independently assess the value and validity of certain types of evidence.
Facilitator Paul Lyons, M.D., of Temple University in Philadelphia acknowledged these difficulties but pointed out, "You don't have to be able to program computers to know how to use one effectively. So perhaps you don't need to know all the nuts and bolts of EBM to use it effectively."
Electronic resources such as the Cochrane Library (http://www.update-software.com/cochrane/) and Bandolier (http://www.jr2.ox.ac.uk/Bandolier/index.html) present "predigested" evidence-based literature analyses on many medical topics, often abrogating the need for physicians to conduct their own critical appraisal of multiple individual studies.
Another session participant noted that some physicians may be discomfited by searching the literature for evidence of an intervention's efficacy, only to discover just how meager that evidence is in many cases. Often, too, different sources of evidence conflict. Lyons responded by saying it's important to bear in mind that building a collection of evidence for or against a given intervention is an ongoing, dynamic process that doesn't always follow a linear path.
What he has found to be key in the educational setting, he added, is ensuring that students comprehend the limitations of EBM: "As teachers, we must guard against instructing students to base clinical decisions on one study. If we're teaching them something that they are then using in an unsophisticated manner, we may be leading them down the path to bad decisions."
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
FP Report | Headlines |AAFP Home | Search