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)
(from “what is evidence based medicine”?)
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.
I clicked the link to read more
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
and others;
● 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.
Heroes Not Zombies 
I totally agree Bob and feel disgusted. The way people are treated by nhs hasn’t changed since I was a child and thats a good number of years ago. This was what put me off using the nhs from the age of 20 till around 40.
Then I was persuaded to try the homeopathic and the quality of service there is:
● Caring and compassionate staff and services;
● Clear communication and explanation about
conditions and treatment;
● Effective collaboration between clinicians, patients
and others;
● A clean and safe care environment;
● Continuity of care; and
● Clinical excellence.
And thats exactly what I wanted and had wanted for years.
We must have a campaign Bob and I am willing to do what I can to get it going.
The resonance I feel when I read your artilce is almost painful. I couldn’t agree more. I work in the nhs and when we are driven towards ‘best practice and clinical effectiveness’, I ask – what about the people who fall out with the ‘crietria’ for the randomised trials? And how can anyone define a group to fit a mould when we all have our own unique personal physical, emotional and spiritual qualites?
What I love about my job (as a physiotherapist) is having the scope to be creative be the way I work with people, to put a hand on the back of an elderly patient who hasn’t experienced the warmth of light touch perhaps since their partner died 25 years ago, to work through simply being present and listening to a story, using a walk outside on the grass in bare feet…..
I agree with Liz, how can we have a voice that can be heard?
I do not work in UK, but it’s the same with us here. I think it’s the same with health care administrations world wide. Administrators and politicians believe that they are looking at things from a higher vantage point and have a better perspective than those who work directly with patients. Maybe they do have a wider perspective, but not necessarily a clearer one. For them Evidence-based medicine is shortened to EBM, and while E can, and should, stand for experience, ethics, expectations, evidence…, it ends up standing only for “economy” and “efficacy”, and efficacy is narrowly defined in terms of dollars and numbers.
[…] claims to certainty by the advocates of those who seek to make decisions about health care solely based on published research are […]
Went on Kaye Adams’ programme on Radio Scotland yesterday morning as this was being discussed. Wanted to point out that it’s only a short time since we went through all this and Glasgow Homeopathic Hospital was not found wanting. It seems incredible that we have to start the arguement all over again. The ‘anti’ person who was guesting was unbelievably patronising to everyone and refused to recognise that ‘anecdotal evidence’ had any value whatsoever.