British Question Evidence Based Medicine
When evaluating the reforms proposed by the government in
Britain, several British scientists in the health field are questioning not only
the reforms but also the concept of evidence based medicine (EBM). Understandably,
British health workers are critical toward the new organizations governing the National
Health Service (NHS) – the National Institute for Clinical Excellence (NICE) and
the Commission for Health Improvement (CHI) – since nobody knows how these new organizations
will be able to improve the NHS.
- Publicerings år: 2000
- Nummer: 2
As an outsider, and not specifically dependent on British health services, it is
disappointing to see many well-known English colleagues use the current situation
to deflate the concept of evidence based medicine. Years ago, the Swedish medical
community adopted the idea that health care should be based on the best available
scientific evidence. The new concept of EBM does not seem to change this fundamental
attitude. It is considered to be an extension of earlier practices.
It may be true that the advent of NICE and CHI can be considered a threat to clinical
freedom. This, however, does not necessarily justify the broad criticism of EBM.
John R Hampton questions the need for NICE, and specific guidelines from such an
organization, as cardiologists know how to interpret the evidence from the many
trials: “Does NICE have any better view of the ‘truth’ than cardiologists who are,
after all, specialists in their field?”
What is evidence based medicine?
The entire EBM concept may seem to be another case of the emperor’s new clothes.
Certainly, we have always aimed to follow the best scientific knowledge in Western
medicine, and the concept of EBM may be only a new way of expressing what has been
common practice for a long time. What is new, however, is the systematic way in
which we search for, arrange, and present knowledge to the medical community. In
Sweden, we view EBM as a systematic way to express reliable knowledge from the world
literature for each type of advice – diagnostic, therapeutic, or prognostic – that
you give a patient.
If you have access to results from randomized controlled trials, good. If you do
not, there may be well-founded scientific results from other studies. If those are
lacking, you may be able to find well-defined observational studies that will help
solve the problem you want to address. EBM does not require decisions to be based
on randomized controlled trials (RCT), only that you know exactly how good the evidence
is in the contemporary literature. Furthermore, EBM does not necessarily imply the
creation of guidelines, but may well be a good foundation for them.
Much of the reasoning behind the criticism aimed at EBM is based on a questionable
interpretation of the concept. What evidence based medicine really stands for can
certainly be discussed. Another issue concerns who within the medical community
will benefit most from it. To assume that EBM will lead only to strict guidelines
that will be enforced by governmental action is not what we want to see in the concept.
Another misunderstanding concerns who is in need of guidelines. Hampton argues that
cardiologists know what they are doing and do not need help from a bureaucratic
governmental organization. Most patients with cardiovascular disease are, however,
not treated by cardiologists but by general practitioners who may need the advice
offered by official guidelines.
Speaking from the experience of SBU, we are not certain that all specialists can
interpret the results of all studies, even within their own fields. Many, if not
most, published trials have deficiencies which must be compensated for. Perhaps
this is better addressed by someone not directly involved with the field the trial
covers. We are not in a position to consider whether there is a need for NICE or
CHI since this is a purely British matter. The definition of evidence based medicine
is of much greater importance, as this definition has bearing throughout the world.
The discussion on the value of guidelines, and the organizations behind them, has
been conducted in a way that suggests the authors may have gone overboard in their
eagerness to denounce the bureaucracy of the NHS when they also reject the concept
of evidence based medicine.
Miles A, Hampton JR, Hurwitz B (ed): NICE, CHI and the NHS Reforms Aesculapius Medical
Press, London 2000.