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EDITORIALS: R Brian Haynes, P J Devereaux, and Gordon H Guyatt Physicians' and patients' choices in evidence based practice BMJ 2002; 324: 1350 [Full text]

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Evidence based medicine was always flawed

Neville W Goodman   (9 June 2002)

Evidence does not make decisions, people "in contexts" do.

Jose L. Turabian, Benjamin Perez-Franco.   (9 June 2002)

Re: Evidence does not make decisions, people "in contexts" do.

R. Brian Haynes   (10 June 2002)

Good communication and Evidence help to make decision

Ansar U Ahmmed   (17 June 2002)

Integrating the evidence base

Nick Barber, Alan Cribb, Director, Centre for Public Policy Research, Kings College London, SE1 8WA   (18 June 2002)

Re: Good communication and Evidence help to make decision

R. Brian Haynes   (23 June 2002)

Re: Integrating the evidence base

Gordon H. Guyatt, R. Brian Haynes, P. J. Devereaux   (24 June 2002)

Evidence based medicine was always flawed 9 June 2002
Neville W Goodman, Consultant Anaesthetist Southmead Hospital, BS10 5NB Send response to journal: Re: Evidence based medicine was always flawed	Haynes, Devereaux and Guyatt write in their editorial, (1) "The notion that decisions may vary from circumstance to circumstance, and from patient to patient with the same circumstances, has received increasing attention." But this is one of the reasons that many have been wary of evidence-based medicine ever since the idea was first described. It underlay Feinstein's worry that medicine was being distracted by quantitative models (2) when so much of clinical medicine, and in particular the doctor-patient consultation, cannot be reduced to numbers. It was implicit when Charlton wrote (3) "epidemiological data do not provide the information necessary to treat individual patients. The error is intractable and intrinsic to the methodological nature of epidemiology, and no amount of statistical jiggery-pokery with huge data sets can make any difference." Haynes et al. write now that "The term evidence based medicine was developed to encourage practitioners and patients to pay due respect - no more, no less - to current best evidence in making decisions." The tone of many earlier articles and editorials, and of much of the correspondence in the journals, invested evidence-based medicine with more authority than that. While I am encouraged that this authority is now on the wane, it is unsettling that the criticisms of Feinstein and others have still not been properly countered, and it is the proponents not the critics who have been given an editorial. 1 Haynes RB, Devereaux PJ, Guyatt GH. Physicians' and patients' choices in evidence based practice. BMJ 2002;324:1350. 2 Feinstein AR. Clinical judgement revisited: the distraction of quantitative models. Ann Int Med 1994;120:799-805. 3 Charlton BG. Book review of Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence based medicine. How to practice and teach EBM. New York: Churchill Livingstone, 1997. J Eval Clin Pract 1997;3:169-172.
Evidence does not make decisions, people "in contexts" do. 9 June 2002
Jose L. Turabian, General Practitioner; Trainer. 45313 Toledo. Spain., Benjamin Perez-Franco. Send response to journal: Re: Evidence does not make decisions, people "in contexts" do.	Haynes, Devereaux, and Guyatt, argue against evidence based medicine (EBM) because of “evidence does not make decisions, people do”, and decisions vary from one patient to another according to individual clinical circumstances and their preferences. So, a new term is proposed - research enhanced health care- to facilitate better use of evidence in clinical practice, especially if the wishes of the patient are taken into account. We want to suggest a shade (especially en general medicine): to make decisions (with people) “in contexts” (1). What is our evidence into our practice and which is constructed? EBM is only one possibility which must be chosen after appraising context, and that must be put in context after their application (2), and there are a lot of general medicine characteristic ways to facilitate make decisions in real life (3, 4). What are these ways used to make “good/proper” clinical decisions in general medicine?: 1.- Internal congruence with doctor (emotion, intuition, ethics, knowledge, reasoning, experience, empathy, empowerment, compassion, creativity, the five senses...); 2.- Congruence with other actors (to put in context, strategic planification, patiens and communities participation, effectiveness, multiple relationships within a ecologycal system...); 3.- Internal congruence with clinical semiology (EBM, clinical epidemiology, congruence of pieces of information from diverse sources...); 4.- Time congruence (continuity of personal medical care, time proof, narrative based medicine...). So, to make decisions -with people- we must begin with the context and only after this to go with the symptoms and signs. REFERENCES: 1.- Turabián JL, Pérez Franco B. Actividades Comunitarias en medicina de familia y atención primaria. Madrid: Díaz de Santos, 2001 2.-Rogers CR. On becoming a person. Boston: Houghton Mifflin Company; 1961 3.-Turabián-Fernández JL, Pérez-Franco B. El futuro de la medicina de familia. Aten Primaria 2001; 28: 657 – 661 4.-Malterud K. The art and science of clinical knowledge: evidence beyond measures and numbers. Lancet 2001; 358: 397-400
Re: Evidence does not make decisions, people "in contexts" do. 10 June 2002
R. Brian Haynes, Professor McMaster University, Hamilton, Ontario, Canada, L8N 3Z5 Send response to journal: Re: Re: Evidence does not make decisions, people "in contexts" do.	In reply to Dr. Turabian, we did not argue "against" Evidence-Based Medicine at all! Rather, we sought to clarify the role we see evidence from research playing in clinical care decisions. We see evidence from research augmenting decisions, not replacing the decision making process. We suggested the term "research enhanced health care" only because we felt this term might be easier to understand. We believe, though, that the term Evidence-Based Medicine and its congeners (Evidence-Based Nursing, etc) will persist and that is fine, as long as we all agree on what it means.
Good communication and Evidence help to make decision 17 June 2002
Ansar U Ahmmed, Consultant Audiological Physician Fulwood Audiology centre, 4 Lytham Road, Fulwood, Preston, PR2 8JB Send response to journal: Re: Good communication and Evidence help to make decision	Editor--------- Hayes et al. highlights the role of clinical state and circumstances, patient’s preferences and actions, and research evidence in clinical care decisions (1). Involving patients in the clinical decision making process is good medical practice, and this improves patient satisfaction and reduces the chances of litigation and complaints (2,3). This can be achieved if clinicians provide the necessary evidence and context-based information to help patients to make an informed choice, but as clinicians we often fail to provide complete information (4). Clinicians sometimes resist withdrawing from established treatments (5) and the issue of evidence based medicine and informed choice gets complicated when clinicians are divided in their opinions. A study has shown, for example, inconsistencies in practice regarding the management of persistent Otitis Media with Effusion in children where the glue recurred following the extrusion of short-term tympanostomy tubes (grommet) on two or more occasion (6,7), despite evidence against one of the options (8,9,10). In this sort of situation can a clinician be accused of confusing the patient/carer by giving too much information by discussing all the options, or could two physicians having two differing opinions be accused of undermining one another? The answer may seem to be obvious but conflicts do arise. Help! References 1. Haynes RB, Devereaux PJ, Guyatt GH. Physicians’ and patients’ choices in evidence based practice. Evidence does not make decisions, people do. BMJ 2002; 324:1350 2. Maintaining Good Medical Practice. General Medical Council, UK. 3. Ernst E and Cohen M. Informed consent in Complementary and Alternative Medicine. Archives of Internal Medicine 2001; 161(19): 2288- 2292 4. Braddock CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed Decision Making in Outpatient Practice: Time to Get Back To Basics. JAMA 1999; 282(24): 2313-2320 5. Haynes B and Haines A. Barriers and bridges to evidence based clinical practice. BMJ 1998; 317:273-276 6. Ahmmed AU, Curley JWA, Newton VE, Mukherjee D. Hearing aids versus ventilation tube in persistent otitis media with effusion: a survey of clinical practice. Journal of Laryngology and Otology 2001; 115:274-279 7. Ahmmed AU, Curley JWA, Newton VE, Mukherjee D. What our colleagues think of long-term tympanostomy tube. Journal of Audiological Medicine (accepted for publication May 2002). 8. Kay DJ, Nelson M, Rosenfeld RM. Meta-analysis of tympanostomy tube sequelae. Otolaryngology Head &Neck Surgery. 2001; 124(4): 374-380 9. Schilder AGM. Assessment of complications of the condition and of the treatment of otitis media with effusion. International Journal of Pediatric Otorhinolaryngology 1999; 49 Suppl. 1: 247 – 251 10. Golz A, Goldenberg D, Netzer A, Westerman LM, Westerman ST, Fradis M, Joachims HZ. Cholesteatomas associated with ventilation tube insertion. Arch Otolaryngol Head Neck Surg 1999; 125(7): 754-757
Integrating the evidence base 18 June 2002
Nick Barber, Professor of the Practice of Pharmacy The School of Pharmacy, London WC1N 1AX, Alan Cribb, Director, Centre for Public Policy Research, Kings College London, SE1 8WA Send response to journal: Re: Integrating the evidence base	EDITOR - We welcome the editorial by Haynes et al (1), which brings together evidence, patient preferences and patient circumstances in an account of clinical expertise, however we would argue for two improvements. First, we think that some notion of the 'public good' needs to be included. Second, we would want to broaden the use of the concept of 'circumstances'. We would redefine expertise in the light of these changes. Our account is rooted in the philosophy and ethics of health care, and we have published it with respect to the definition of good prescribing (2), however we suggest it is of equal relevance for other areas of clinical expertise. As with all ethics the difficulty is not merely to differentiate between good and bad, but also between conflicting versions of what is good. Thus, whilst it is certainly good to take into account patients' preferences, it can also be good, on occasions, to do things which override them in order to benefit society as a whole. For example, to isolate patients with certain diseases, or to restrict antibiotic use. Whilst these consideration may not be salient in all consultations, they must be acknowledged in any model, if only to be discounted in practice. Like Haynes et al we argue that the evidence base has to be balanced with a wider notion of the patient's good, which reflects their preferences and circumstances. But we also argue that this balancing act cannot be enacted in isolation from a consideration of broader types of good. In practice the balances one strikes between the conflicting dimensions of good, can only be resolved by taking the relevant circumstances into account. We would widen the understanding of circumstances, so that it encompassed any factors which might be relevant to the case in hand. This may include such things as family circumstances, local policy, and the relationship between doctor and patient. Expertise, in our view, is the ability to make a good judgement against this complex field of evidence, values and circumstances. This requires both (a) an appreciation of the strengths and weaknesses of evidence and the nature of scientific knowledge, and (b) an orientation towards the patient and the patient's life-world. But it also requires an openness to a broader range of values and contextual factors, and of course - above all - practical experience of the ways these many factors play out in different circumstances. 1 Haynes RB, Devereaux PJ, Guyatt GH. Physicians' and patients' choices in evidence based practice. BMJ 2002;324:1350 2 Cribb A, Barber N. Prescribers, patients and policy: the limits of technique. Health Care Analysis 1997;5:292-298
Re: Good communication and Evidence help to make decision 23 June 2002
R. Brian Haynes, Professor of Clinical Epidemiology and Medicine McMaster University, Hamilton, ON, Canada L8N 3Z5 Send response to journal: Re: Re: Good communication and Evidence help to make decision	Dr. Ahmmed raises a valuable point about what a doctor should do when the evidence from research is clear but another doctor insists on sticking with an outdated practice - does providing this information to the patient/carer confuse them or undermine the patient's relationship with one or both physicians? Certainly there is a risk here, and weighing that risk would be a matter for exercising one's judgement (under the rubric of "clinical expertise" in our model). This risk may be judged to be too great to proceed along the obvious path dictated by "nothing ventured nothing gained". But the latter path must be the preferred one, as simple reflection illustrates: what if it is your own ear that is glued and a doctor is recommending a practice that flies in the face of current best evidence? Presuming that you yourself would want to know the evidence concerning this practice, you should accord the same respect for the patient/carer whenever the patient requests this information of you. The patient/carer can then decide which of the options they prefer.
Re: Integrating the evidence base 24 June 2002
Gordon H. Guyatt, Professor of Clinical Epidemiology and Medicine McMaster University, Hamilton, ON L8N 3Z5 Canada, R. Brian Haynes, P. J. Devereaux Send response to journal: Re: Re: Integrating the evidence base	Barber and Cribb make important points with which we agree. Like these authors, we believe that clinical decision-making must go beyond the interests of the individual patient to the society of which the patient, and the physician, are a part. Furthermore, it would be a limited physician indeed who would neglect issues of family circumstances, local standards, and the relationship between the physician and the patient. Any model of clinical decision-making will, of necessity, be an oversimplification. In our model, we chose to highlight issues of evidence, circumstances, and individual patient values. This decision rested on our perception about the nature of current clinical practice. We believe that clinicians often fail to clearly delineate the crucial value or preference judgements underlying clinical decisions. How to most effectively communicate information to patients, and incorporate their values, remains a frontier of evidence-based decision making. For now, and for the limited space of a BMJ editorial, we felt highlighting these issues was sufficient. In much longer expositions of the philosophy of evidence-based medicine, we have dealt in detail with the societal and humanistic considerations that Barber and Cribb point out (1,2). 1. Guyatt G, Haynes RB, Jaeschke R, Cook D, Greenhalgh T, Meade M, Green L, Naylor CD, Wilson M, McCalister F, Richardson S. The philosophy of evidence-based medicine. In: Guyatt G, Rennie D. The Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. AMA publications, 2002. 2. Haynes RB. What kind of evidence is it that Evidence-Based Medicine advocates want health care providers and consumers to pay attention to? BMC Health Services Research 2002;2:3