This blog posting is a response to the following paper now available online
Greenhalgh, T., Howick, J., Maskrey, N., 2014. Evidence based medicine: a movement in crisis? BMJ 348, http://www.bmj.com/content/348/bmj.g3725
It is also of interest to reflect on the problems and solutions copied below and to think how many of these kinds of issues can also be seen in development aid programs.
According to the paper, the problems with the current version of evidence based medicine include:
- Distortion of the evidence based brand ("The first problem is that the evidence based “quality mark” has been misappropriated and distorted by vested interests. In particular, the drug and medical devices industries increasingly set the research agenda. They define what counts as disease ... They also decide which tests and treatments will be compared in empirical studies and choose (often surrogate) outcome measures for establishing “efficacy.”
- Too much evidence: The second aspect of evidence based medicine’s crisis (and yet, ironically, also a measure of its success) is the sheer volume of evidence available. In particular, the number of clinical guidelines is now both unmanageable and unfathomable. One 2005 audit of a 24 hour medical take in an acute hospital, for example, included 18 patients with 44 diagnoses and identified 3679 pages of national guidelines (an estimated 122 hours ofreading) relevant to their immediate care"
- Marginal gains and a shift from disease to risk: "Large trials designed to achieve marginal gains in a near saturated therapeutic field typically overestimate potential benefits (because trial samples are unrepresentative and, if the trial is overpowered, effects may be statistically but not clinically significant) and underestimate harms (because adverse events tend to be under detected or under reported)."
- Overemphasis on following algorithmic rules: "Well intentioned efforts to automate use of evidence through computerised decision support systems, structured templates, and point of care prompts can crowd out the local,individualised, and patient initiated elements of the clinical consultation"
- Poor fit for multi-morbidity. "Multi-morbidity (a single condition only in name) affects every person differently and seems to defy efforts to produce or apply objective scores, metrics, interventions, or guidelines"
- Individualised for the patient: Real evidence based medicine has the care of individual patients as its top priority, asking, “what is the best course of action for this patient, in these circumstances, at this point in their illness or condition?” It consciously and reflexively refuses to let process (doing tests, prescribing medicines) dominate outcomes (the agreed goal of management in an individual case).
- Judgment not rules. Real evidence based medicine is not bound by rules.
- Aligned with professional, relationship based care. Research evidence may still be key to making the right decision—but it does not determine that decision. Clinicians may provide information, but they are also trained to make ethical and technical judgments, and they hold a socially recognised role to care, comfort, and bear witness to suffering.
- Public health dimension . Although we have focused on individual clinical care, there is also an important evidence base relating to population level interventions aimed at improving public health (such as pricing and labelling of consumables, fluoridation of water, and sex education). These are often complex, multifaceted programmes with important ethical and practical dimensions, but the same principles apply as in clinical care.
- Delivering real evidence based medicine. To deliver real evidence based medicine, the movement’s stakeholders must be proactive and persistent. Patients (for whose care the movement exists) must demand better evidence, better presented, better explained, and applied in a more personalised way with sensitivity to context and individual goals.
- Training must be reoriented from rule following Critical appraisal skills—including basic numeracy, electronic database searching, and the ability systematically to ask questions of a research study—are prerequisites for competence in evidence based medicine. But clinicians need to be able to apply them to real case examples.
- Evidence must be usable as well as robust. Another precondition for real evidence based medicine is that those who produce and summarise research evidence must attend more closely to the needs of those who might use it
- Publishers must raise the bar. This raises an imperative for publishing standards. Just as journal editors shifted the expression of probability from potentially misleading P values to more meaningful confidence intervals by requiring them in publication standards, so they should now raise the bar for authors to improve the usability of evidence, and especially to require that research findings are presented in a way that informs individualised conversations.
- ...and more
The risk lies in seeing two alternative modes of practice as exclusive choices. One is rule based, focused on average affects when trying to meet common needs in populations and the other is expertise focused on the specific and often unique needs of individuals. Parallels could be drawn between different type of aid programs, e.g. centrally planned and nationally rolled out services meeting basic needs like water supply or education and much more person centered participatory rural development programs
Alternatively, one can see these two approaches as having complementary roles that can help and enrich each other. The authors describe one theory of learning which probably applies in many fields, including medicine: The first stage " ...beginning with the novice who learns the basic rules and applies them mechanically with no attention to context. The next two stages involve increasing depth of knowledge and sensitivity to context when applying rules. In the fourth and fifth stages, rule following gives way to expert judgments, characterised by rapid, intuitive reasoning informed by imagination, common sense, and judiciously selected research evidence and other rules" During this process a lot of explicit knowledge become tacit, and almost automated, with conscious attention left for the more case specific features of a situation. It is an economic use of human cognitive powers. Michael Polanyi wrote about this process years ago (1966, The Tacit Dimension).
The other side of this process is when tacit knowledge gets converted into explicit knowledge. That's what some anthropologists and ethnographers do. They seek to get into the inner world of their subjects and to make it accessible to others. One practitioner whose work interests me in particular is Christina Gladwin, who wrote a book on Ethnographic Decision Trees in 1989. This was all about eliciting how people, like small farmers in west Africa, made decisions about what crops to plant. The result was a decision tree model, that summarised all the key choices farmers could make, and the final outcomes those different choices would lead to. This was not a model of how they actually thought, but a model of how different combinations of choices were associated with different outcomes of interest. These decision trees are not so far removed from those used in medical practice today.
A new farmer coming into the same location could arguably make use of such a decision tree to decide what to crops to plant. Alternatively they could work with one of the farmers for a number of seasons, which then might cover all the eventualities in the decision tree, and learn from that direct experience. But this would take much more time. In this type of setting explicit rule based knowledge is an easier and quicker means of transferring knowledge between people. Rule based knowledge that can be quickly and reliably communicated is also testable knowledge. Following the same pattern of rules may or may not always lead to the expected outcome in another context.
And now a word about algorithms. An algorithm is a clearly defined sequence of steps that will lead to a desired end, sometimes involving some iteration until that end state gets closer. A sequence of choices in a decision tree is an algorithm. At each choice point the answer will dictate what choices to be made next. These are the rules mentioned in the paper above. There are also algorithms for constructing such algorithms. On this blog I have made a number of postings about QCA and (automated) Decision Tree models, both of which are means of constructing testable causal models. Both involve computerised processes for finding rules that best predict outcomes of interest. I think they have a lot of potential in the field of development aid.
But returning to the problems of evidence based medicine, it is very important to note that algorithms are means of achieving specific goals. Deciding which goals need to be pursued remains a very human choice. Even within the use of both QCA and (automated) Decision tree modeling users have to decide the extent to which they want to focus on finding rules that are very accurate or those which are less accurate but which apply to a wider range of circumstances (usually simple rather than complex rules).
So, in summary, in any move towards evidence based practice, we need to ensure that tacit and explicit forms of knowledge build upon each other rather than getting separated as different and competing forms of knowledge. And while we should develop, test and use good algorithms, we should remember they are always means to an end, and we remain responsible for choosing the ends we are trying to achieve.