In this essay we will discuss about:- 1. Definition of EBM 2. Why EBM is Needed ? 3. Steps.
Essay # 1. Definition of Evidence Based Medicine (EBM):
One of the commonest definitions is as follows:
“EBM is the conscientious, explicit and judicious use of current best evidence in making the best decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”
The clinical expertise means the treating physician’s medical knowledge, experience and clinical skills accumulated over years of practice. It also means understanding the uniqueness of each individual patient as well as knowing the risks and benefits of adopting a specific therapeutic strategy for him.
This involves taking into consideration the values and expectations of each patient in addition to selection of the therapeutic agent most suited for him.
The values encompass the patient’s concerns, demands and preferences of treatment. The evidence comes from the published research materials, but their goodness and applicability are a function of their clinical relevance and sound research methodology as judged statistically. New strategies may invalidate and replace older ones when evidence indicates that the new strategies are safer, more precise and more efficacious.
Three other definitions of EBM are the following:
(1) “An approach to health care practice in which the clinician is aware of the evidence in support of his or her clinical practice, and the strength of that evidence”.
(2) “Integration of best research evidence with clinical expertise and patient values”;
(3) “The new paradigm deemphasising intuition, unsystematic clinical experience, and pathophysiological rationale as sufficient grounds for clinical decision making and stressing the examination of evidence from clinical research”.
Thus evidence based medicine is a medical approach which blends sound clinical judgement, the patient’s expectations and the best available evidence with reference to a therapeutic strategy. However in psychiatry its most important use today is in selecting therapeutic strategies.
It differs from the most commonly adopted traditional “replicating” model in that it does not seek or accept “blindly” strategies which have been “dictated” or “recommended” by “authorities”, including “standard textbooks” and “expert opinions”, without critical evaluation.
Apart from being a patient care model, evidence based medicine is also a “lifelong learning model”.
Essay # 2. Why EBM is Needed?
There are several reasons why an evidence based learning approach is necessary.
a. Information Needs:
All physicians have considerable needs for valid information with respect to their patient, centred on their diagnosis, treatment including prevention and the final outcome. Many of the information needs are often unrecognised or not met.
b. Inadequacy of Usual Ssources of Information:
The usual sources of information include textbooks, other medical literature (journals, etc.), expert opinions and didactic lectures. Of these, textbooks are often outdated and inaccessible, medical literature (review articles, information provided by medical firms, etc.) is often subjectively biased and varied, in addition to its being too voluminous; expert opinions are again “Opinions only” and not necessarily critically evaluated and didactic lectures are most often ineffective and impractical.
c. Lack of Information and Lack of Time:
The lack of information about the available resources and a lack of time may also contribute in making the needed information inaccessible.
d. Information Eexplosion:
There is an overwhelming explosion of medical data and their dissemination over the years. It becomes necessary to restrict search to a smaller field and to modify scanning methods so as to avail the needed information after ensuing soundness of methodology and validity of results.
e. Idiosyncratic Practice Modes:
An indirect effect of the information explosion is that individual practitioners unable to differentiate valid data from the rest, resort to varied and often idiosyncratic modes of clinical practice guided solely by self-assumptions that their decisions are the best clinical decisions. In reality, however they may not be the best decisions in the absence of any supporting evidence to validate the assumption.
Essay # 3. Steps in the EBM Process:
Practice of EBM involves five successive steps:
They are following:
1. Formulation of a well-defined answerable question regarding the patient’s clinical condition.
2. Tracking down the available resources and searching them for information pertaining to a particular question.
3. Critical evaluation of the evidence for its validity and clinical applicability.
4. Making a decision and integrating it with the clinical expertise to manage the patient.
5. Evaluation of the performance.
Criticisms:
As for any new approach in medicine EBM also has its own critics and supporters. The critics hold that the message of EBM is not new and had been followed in medical practice all along. Some point out that there is no real proof for EBM’s effectiveness over the traditional approaches.
EBM takes away clinical freedom and all credit is given to evidence rather than to clinical judgement. EBM resorts to application of population studies direct to individuals without considering their uniqueness of personality and circumstances.
On the other hand supporters of EBM claim that clinical decisions are based on stronger evidence obtained through sound methodology. They point out that traditionally less than 5% of clinical decisions are evidence based.
Many are made on strong consensus among physicians. But half of all clinical decisions are based neither on evidence nor on consensus. Individual values and expectations and their uniqueness are given due consideration which they say is an important step in EBM.
When randomised control studies are lacking, the clinician is free to choose other kinds of evidence next in the hierarchy scale. Traditional medical skills are not downplayed but instead they are supported and strengthened by EBM. EBM closes the gap between research and practice, optimises clinical decisions and allows the practitioners to justify their decisions. According to them it makes clinical practice easier, safer and more effective.