Evidence based medicine and the medical curriculum
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1253 (Published 24 September 2008) Cite this as: BMJ 2008;337:a1253
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Well written article on evidence based medicine. The tutors of the
curriculum/consultants in various hospitals need to be taught how to
understand research (NOT TO DO research. Only then they can teach the
students
Competing interests:
None declared
Competing interests: No competing interests
So much store is set these days on Evidence Based Medicine, but so
much that I read rarely takes into account evidence outside the narrow
confines of the subject in question. In all science, an ability to see the
much broader implications of the question is an essential feature. The
implications in other organisms, organs, or functions are studiously
ignored, and no thought is given to effects outside the box of the moment.
This is seen in the studies and trials which are carried out within
the confines of one specialism, with virtually total disregard to the
consequences to others. Could this be due to a desire to make the greatest
use of research funding solely within the originating establishment or
organisation? The public interest is not served by such "possesion" of
particular subjects by just one specialism.
Treatments for one condition should not merely be measured in
isolation, but all the possible ramifications in other areas should be
vigorously sought out, without the influence of the "pet" subject of a
particular group having the monopoly of decision making on the outcome.
Competing interests:
Statin damaged patient
Competing interests: No competing interests
We would be delighted if - as Dr Reveiz suggests - all high school
students learned more about scientific method, rather than just the
results of science. In addition, they should learn to reason about
probability, not simply do probability calculations. Whether or not this
happens at school, evidence and probability should certainly be taught in
medical school but often is not. According to our recent survey, Simon
Thornton is lucky to have attended a UK medical with one of the better
curriculums in EBM, but many still have minimal teaching. As we suggested
in the editorial, each medical school should have an EBM coordinator who
helps to harmonize the teaching from clinicians, librarians (such as those
in Leicester), epidemiologists, statisticians, clinical pharmacologists
and all those engaged in some elements of EBM so there is a coherent
vertical curriculum.
Competing interests:
Author of the editorial
Competing interests: No competing interests
Buy a personal subscription to an EBM resource. It's not that
expensive, and it'll safeguard your patients and your career.
There are several publishers falling over themselves to provide this
information, one of them being BMJ Group. Other alternatives are
Elsevier's MDConsult or Wolters Kluwer's UpToDate.
Competing interests:
I formerly worked for Elsevier, and I currently work for a Reed Elsevier Group company.
Competing interests: No competing interests
It is ironic that the week that the BMJ publishes an editorial on the
importance of accessing and critically appraising evidence, staff in NHS
Wales have lost the access to electronic databases and journals previously
available through the Health of Wales Information Service (HOWIS). This
appears to betray a lack of understanding of the importance of evidence
based decision making, both in clinical care and policy making. Sadly,
unless this decision is reversed, NHS Wales staff will indeed be reliant
on Google and Wikipedia for their evidence.
Competing interests:
I work in NHS Wales
Competing interests: No competing interests
This is an interesting and well argued piece. Librarians have a
vital role in supporting evidence based medicine, using our professional
skills to help develop the skills described here. At the University of
Leicester, our medical students have compulsory classes with subject
specialist librarians, covering searching skills (that we hope enable them
to find “potentially relevant studies quickly and reliably”), and sources
of evidence based information including the Cochrane Library, Clinical
Knowledge Summaries, and DynaMed. Increasingly I am finding myself
teaching basic critical appraisal skills across the biomedical sciences as
a whole.
Clinical librarians in the UK and elsewhere also support practising
doctors and other health professionals by searching, selecting and
appraising literature on behalf of practitioners who do not have the time,
or perhaps the skills, to do this for themselves.
Competing interests:
None declared
Competing interests: No competing interests
There is no doubt that the teaching of evidence based medicine (EBM)
should be an integral part of the undergraduate and postgraduate
curriculum. Tomorrow's Doctors states "Graduates must know about and
understand the principles of treatment including... how to evaluate
effectiveness against evidence".(1) The article by Glasziou et al (2)
emphasises the importance of EBM within the curriculum but this may be
more widespread than the authors portray. Having (relatively) recently
graduated from Bristol medical school I feel we received thorough
grounding in EBM and critical appraisal. It is one of five key vertical
themes that run throughout the five year course,(3) and one of the core
components of the Foundation Programme Curriculum.(4) The difficulty comes
in regularly applying these skills in a clinical setting, and in my
experience this is due to lack of time not good intention. Should formal
time be set a side in the 48 hours each week doctors are given to develop
all their necessary skills? Probably not. But for those who wish to do it
in their own time, might I recommend the BestBETS website which was
developed in the Emergency Department of Manchester Royal Infirmary to
"provide rapid evidence-based answers to real-life clinical questions,
using a systematic approach to reviewing the literature".(5)
1. Tomorrow's Doctors GMC 2002
2. Glasziou P, Burls A, Gilbert R. Evidence based medicine and the
medical curriculum. BMJ 2008;337:704-705
3. MBChB Programme Handbook, University of Bristol 2008
4. The Foundation Progamme Curriculum 2007
5. http://www.bestbets.org/ Accessed 28/09/2009
Competing interests:
None declared
Competing interests: No competing interests
A scientific method consists of “the collection of data through
observation and experimentation, and the formulation and testing of
hypotheses”. Evidence-based medicine (EBM) intend to apply evidence gained
from the scientific method to medical practice. It is the process of
systematically finding, appraising, analyzing and using research findings
as the basis for clinical decisions and problem solving. Glasziou et al
(2) suggested that evidence based basic skills of using research “should
be taught early and applied as an integral part of learning in all years
of the (medical) curriculum”.
Actually, “Evidence based thinking” should also be incorporate in
elementary and high school curriculum to permit school students to
discover the scientific method and to explore the problems according to
the evidence. Developing the skills of the school students will also help
to incorporate "evidence based thinking" in other fields.
1. From Wikipedia, Scientific method. URL available from
http://en.wikipedia.org/wiki/Scientific_method. Access in September 2008.
2. Glasziou P, Burls A, Gilbert R. Evidence based medicine and the
medical curriculum. BMJ. 2008 24;337:a1253.
Competing interests:
None declared
Competing interests: No competing interests
The popularity of EBM is proportional to the failures of medicine itself
Since the term Evidence-Based Medicine (EBM) was created in the early
1990s, the adjective “Evidence-Based” has spread to various sectors of
science and humanities, e.g. sociology, psychology, education, crime
prevention, history, etc. It is however in medicine that the adjective has
met with its greatest popularity.
Let us first have a look at the definition of EBM given in 1996 by
some of its creators: “Evidence based medicine is the conscientious,
explicit, and judicious use of current best evidence in making decisions
about the care of individual patients. The practice of evidence based
medicine means integrating individual clinical expertise with the best
available external clinical evidence from systematic research” [1].
As already pointed out by others [2], such a definition is so broad
that it could indeed be an accurate definition of modern medicine itself,
all the more since the definition of EBM was refined over the years, and
it now integrates the four basic principle of medical ethics, i.e.
autonomy, beneficence, non-maleficence and justice [3], via the use of
words such as patients’ values and preferences, balance between benefits
and harms, costs and resource utilisation [4]. In the EBM world the four
ethical principles now determine whether a recommendation should be graded
strong or weak [5].
Who could possibly be opposed to a medical practice that would use
the best scientific evidence wisely, and ethically?
In our view, the most likely explanation for the popularity of EBM
is the very fact that its scope is so broad that it is nicely suited to
compensate for many failures and irrationalities within clinical practice,
and health care systems [5]. Otherwise it would not have been deemed
necessary to create this "new" term: the already existing term "medicine"
(which already means all what EBM is supposed to mean) would have sufficed
for most of us. Thus viewed, the popularity of EBM is likely to
proportional to the failures of medicine itself.
References:
1) Sackett DL, Rosenberg WC, Muir-Gray JA, Haynes RB, Richardson WS.
Evidence based medicine: what it is and what it isn't. BMJ 1996; 312: 71-
2.
2) Sehon SR, Stanley DE. A philosophical analysis of the evidence-
based medicine debate. BMC Health Serv Res 2003; 3:14.
3) Gillon R. Medical ethics: four principles plus attention to scope.
BMY 1994; 309:184-8.
4) Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based
Medicine. 3rd edition, 2005.
5) Atkins D, Best D, Briss PA et al; GRADE Working Group. Grading
quality of evidence and strength of recommendations. BMJ 2004; 328:1490.
6) Raspe H. [Evidence-based medicine: popular nonsense, old wine in
new bottles or current necessity?] Z Arztl Fortbild 1996; 90:553-62
[Article in German].
Competing interests:
None declared
Competing interests: No competing interests