I think the original definition of “evidence based medicine” was a good one –
EBM is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology. (Sackett D, 2002)
But what’s happened to it? Frequently it seems to be reduced to reading summaries of randomised controlled trials then applying those conclusions to everyone. In other words, forget the “clinician’s cumulated experience, education and clinical skills” because it might produce “variance”, and dismiss the patients’ “unique concerns, expectations, and values” as irrelevant. It’s that kind of thinking which led to a young doctor telling me she’d been taught “If a patient takes an evidence based drug and says they aren’t any better, then, either they haven’t taken the drug, or they’re lying.” Clinicians’ cumulated experience will tell you that there isn’t a drug on the planet which will deliver the same outcomes for every single patient who takes it, and as health is a subjective human experience, the patients’ concerns and values can only be dismissed at the cost of failing to deliver effective health care.
So, I was somewhat surprised when I got last week’s BMA Scotland newsletter. Under the heading “Healthcare Quality Strategy for the NHS in Scotland is published”, it said
The Healthcare Quality Strategy has been published by the Scottish government. BMA Scotland believes by focusing on evidence-based policy with proven clinical outcomes for patients, limited resources can be used effectively to deliver improvements to the care and treatment of patients.
Here’s what it says on the first page –
People in Scotland have told us that they need and
want the following things from the NHS and we have
built this strategy around these priorities:
● Caring and compassionate staff and services;
● Clear communication and explanation about
conditions and treatment;
● Effective collaboration between clinicians, patients
● A clean and safe care environment;
● Continuity of care; and
● Clinical excellence.
So, how does the BMA manage to get from the document to their summary? Why no mention of the priorities focused on care, compassion, communication, collaboration, cleanliness and continuity of care? Why pick only the last priority and characterise that as a way of rationing medical care according to “proven clinical outcomes”?
Really, it’s high time we put human beings back at the CENTRE of health care…..the patients and the carers……just as it says in the rather excellent “Healthcare Quality Strategy for the NHS in Scotland”. Read it for yourself and see if you agree.