Letters

Towards a knowledge based health service May lead to more red tape

BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6956.740c (Published 17 September 1994) Cite this as: BMJ 1994;309:740
  1. B G Charlton
  1. Department of Epidemiology and Public Health, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH
  2. Department of Public Health Medicine, University of Sheffield Medical School, Sheffield S10 2RX.

    EDITOR, — A “knowledge based health service” would seem to be something of which we might all approve. Yet the means proposed for reaching this desirable end give serious cause for concern. A new regulatory scheme is proposed whereby research managers will evaluate the evidence on science and health technologies and will “see that the results are introduced into practice.”1 Clearly, this process would be prone to the political influences, exploitation by pressure groups, and short term expediency that have affected all other aspects of NHS management.

    The old model for incorporating science into clinical work was based on education and the self motivation of professionals.2 This model was able to respond to the development of scientific medicine throughout the 20th century to produce massive changes in health service practices. Of course this model is imperfect; nevertheless, remarkable progress towards evidence based medicine has been achieved, especially in Britain. The facts comprehensively refute the accusation of a “failure of research to feed through to practice”1; failure compared with what? Research does feed through to practice, although perhaps not as fast or as completely as everybody might wish in an ideal world.

    Under the new arrangements, clinical responsibility will be taken from doctors in practice and instead be vested with executive committees; this could prove to be a grave error of judgment.2 The basis for this new managerial system is the so called “science of critical reviews of the literature” - in other words, systematic overviews and meta-analyses. But meta-analysis is not a science; it is merely a more explicit and systematised way in which a new breed of experts in critical appraisal can write an old fashioned review article.3 Meta-analysis does not form part of the hard biological sciences such as molecular biology; the need for it is a consequence of decision making in the face of scientific uncertainty.

    In a truly knowledge based health service, knowledge must be dispersed throughout the system,2 along with the clinical responsibility for using that knowledge in practice. The method should be to strengthen education rather than regulation. There are, of course, a minority of doctors who (dangerously) persist in obsolete practices or fail to introduce proved improvements.4 The answer is to reform disciplinary mechanisms, making them tougher. We should tackle the doctors at fault rather than tangling all doctors in more red tape and introducing a system of pseudoscience by diktat.

    References

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    Teaching evidence based medicine in Sheffield

    1. K Perrett,
    2. P Silcocks,
    3. R A Dixon,
    4. J Munro
    1. Department of Epidemiology and Public Health, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH
    2. Department of Public Health Medicine, University of Sheffield Medical School, Sheffield S10 2RX.

      EDITOR, — Richard Smith rightly describes the training of medical students in scientific methods and critical appraisal as minimal.1 We will attempt to plug this gap in the coming academic year, when a new course, principles of evidence based medicine, will be introduced for first year students from their first week at the University of Sheffield Medical School.

      This approach is based on the work of the Evidence Based Medicine Working Group at McMaster University,2 and the rationale derives largely from the General Medical Council's recent recommendations concerning undergraduate medical education.3 In evidence based medicine critical appraisal is not an end in itself but one element of a cycle requiring a range of skills, which include recognising and defining a problem, searching the literature, selecting appropriate articles, appraising their quality as evidence, judging their applicability to the problem, reaching a conclusion, and using judgment based on first principles when suitable evidence does not exist.

      In Sheffield's course on evidence based medicine, which will span the first two undergraduate years, traditional teaching of epidemiology and medical statistics will be wholly replaced by problem solving tutorials, in which students will work cooperatively in small groups. Because of the different method of selecting students at McMaster University, our students will be introduced to the practice of reading and assessing publications by means of structured exercises that link a clinical scenario to a relevant article. As students progress through their training these skills will be applied in an increasingly sophisticated way to solve everyday clinical problems. The skills learnt will include critical appraisal, self directed learning, and group working besides the theory and applications of epidemiology and biostatistics.

      As our medical school revises the later years of the undergraduate curriculum we look to our clinical colleagues to put the principles of evidence based medicine into practice so that we train a new generation of doctors who will be practising more of the science, as well as the art, of medicine and who will contribute to the knowledge based health service that Smith envisages.

      References

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