Evidence-based medicine is the basis of sound healthcare

Shobha Shukla and Bobby Ramakant, CNS
Dr Gordon Guyatt
Evidence based medicine (EBM) emphasizes the use of evidence from robust research in healthcare decision-making. It is the conscientious and judicious use of current available best evidence in making decisions about the care of individual patients. It integrates individual clinical expertise with the best available external clinical evidence obtained from systematic research and with the patient's values and expectations. It informs the doctor which drugs and procedures are best for treating diseases.

Modern healthcare is undergoing the much needed evolution in terms of understanding and adopting EBM. Systematic reviews collate all evidence in order to address a specific research problem by using explicit and systematic methods.

It was Dr Gordon Guyatt of Macmaster University, Canada, who had first coined the term ‘evidence based medicine’ in 1990. In an interview with Citizen News Service (CNS) at the 22nd Cochrane Colloquium being held in Hyderabad, India, he spoke about his fascination with this very important component of quality healthcare. It would be apt to mention here that The Cochrane Collaboration is acknowledged as a world leader in the EBM sector, with a reputation for producing high quality, credible information to inform public health decision-making.

According to Dr Guyatt, EBM is about "using the medical literature in the best way to guide patient care."

He said that, "One important principle epitomised by the Cochrane Collaboration is that you need a systematic review of all the best evidences, take all the relevant best evidences and then apply them in your relevant field. At times studies may give conflicting statements: one study may show that X is beneficial or harmful and then few months later there might be another study telling just the opposite. The way around this confusion is to have systematic summaries of the best evidences available and resolve the dilemma of contradictions between individual studies that show different results."

"EBM also gives us a set of principles to judge what is more trustworthy and what is less trustworthy. Surprisingly, evidence by itself  can never tell us in totality what to do, as there are often very close tradeoffs and so some people may choose one and some may choose the other. EBM simply points out the best evidence, the desirable and undesirable consequences, and highlights the fact that values and preferences are necessary to make the right choice for a particular individual."

The relevance of EBM in public healthcare has definitely grown over the past few years. The Cochrane Collaboration and Colloquium is one example of how the principles of EBM and systematic summaries of the best evidence can join hands and reflect in better healthcare. Many medical textbooks now emphasize evidence -based approaches towards health and in many countries medical students are taught to learn how to medical literature optimally in patient-care.

Yet, applying EBM in healthcare faces many practical challenges, especially in developing countries. Dr Guyatt agreed that, “It is practically not feasible for any medical practitioner to be able to read all the available studies and process them. What they need is preprocessed information in the form of trustworthy guidelines and trustworthy reviews like those provided by Cochrane. Also, they need guidelines presented in a way that is easy to process, that is easy to understand, and at the same time allows them to delve more deeply into the issue if they want to. We are getting better in presenting guidelines in a way that is easy for the clinician and potentially eventually for the patient to understand it. Fortunately, electronic communication is making things easier and better. Widespread use of electronic textbooks is helping in this dissemination process."

According to Dr Guyatt, “Guidelines for clinicians should be like an ‘onion’—they should have layers. The doctor might just want to know what should he do and the first layer suggests a particular option, but then sometimes the right thing to do might depend upon the values and preferences of the patient. So the next layer might tell the rationale for this recommendation. The next layer might dwell upon the effects of the treatment or the side effects like stroke, bleeding, and other practical consequences. In this way a practitioner can go deeper and deeper as is necessary or desirable in a particular context.”

“The doctor is free to stop at the first layer and tell the patient that this is what should be done. But now the idea of shared decision-making (between doctor and patient) is gaining ground, especially in the developed countries, because the right treatment decision is likely to differ across patients. If the doctor stops at the first layer then she/he will not understand enough to actually participate in shared decision making. But it at least gives the alternative-- ready access to results that are presented in a way they understand and they can go as deep as they choose.”

At 22nd Cochrane Colloquium, Dr Gordon Guyatt will also be releasing the third edition of the definitive text for evidence-based practice: "The Users' Guide to the Medical Literature." Like the first two editions, the third edition includes a shorter version for most medical students, trainees, and practicing clinicians - "The Essentials". Like the first two editions, this third edition also represents the clearest available, most lucid exposition of EBM, and of using the literature to guide patient-care. 

After crossing the frontiers of the West, the influence of EBM is fast gaining ground in developing countries too. In the context of this conference it is great to be having it in South Asia (first time-ever Cochrane Colloquium is being held in this region) and it just shows that the influence is worldwide.  The middle and low income countries are the new and real frontiers of dissemination of EBM concept which is amply reflected in the theme of the conference--Evidence-informed Public Health: Opportunities and Challenges.

Shobha Shukla and Bobby Ramakant
Citizen News Service - CNS
22 September 2014