I am writing this blog to complement a podcast I made at the recent EvidenceLive conference in Oxford. We were asked to propose a dangerous idea in relation to the future of EBM, and then to suggest a solution. My idea is about recognising, and making explicit the quality of all components of clinical decision making in evidence-based health care.
The current ‘real vs rubbish EBM‘ debate encourages clinicians to consider the research evidence, in conjunction with patient wishes and the clinician’s expertise; just as Dave Sackett exhorted over 20 years ago, at the inception of evidence-based practice. More recently, there has been a recognition that all clinical decisions are made within a local context of people, organisations and resources.
So my explanation of this dilemma is about recognising and promoting the quality of 4 key components of clinical decision making (research evidence, patient wishes, clinician expertise and local context). But what is quality? It is most commonly described as a state of excellence, and there are numerous initiatives within healthcare to improve quality through the identification and measurement of key components.
Having identified 4 key components of evidence-based health care, the real challenge is how can we identify, measure and evaluate the quality of the knowledge from each component that contributes to real time clinical decision making?
- for the component of research evidence, we have made major advances over the last 20 years in terms of understanding the quality of study designs suitable for answering important clinical questions; we have developed critical appraisal and quality reporting tools and checklists to evaluate the quality of the research evidence at the core of a clinical decision; using the key steps of evidence-based practice, we have taught many clinicians explicit and effective ways to identify, search for and critically appraise research evidence to answer specific clinical queries
- with respect to patient wishes, there are tools developed to help patients understand risk and bias, so they can recognise that every intervention has potential benefits and harms; and the concept of shared decision making highlights the importance of informing patients about the comparative benefits and harms when the research evidence is uncertain; however it is difficult for busy clinicians to consistently identify and incorporate patient values in clinical decisions
- in the component of the clinician’s expertise, clinical experience has long been discounted as the lowest form of research evidence, yet it is clinicians who develop their practice through using a combination of their own tacit experience and clinical reasoning skills; therefore if we recognise these locally relevant inductive explanations or mindlines, can we make them more transparent so that they can be tested and developed for other clinicians?
- with respect to the local context, we know from the relatively new field of implementation science that certain patterns of resources and people can function as barriers or facilitators to using research evidence and other forms of knowledge to make clinical decisions; we also know that organisations which encourage innovation, data collection and analysis, and critical appraisal are more likely to use and apply research evidence; so it is important to identify and validate tools that can examine the capacity of individuals and health organisations to evaluate there local context as a basis for using research.
Therefore, it is time we need to move outside of our current paradigms to understand the contribution of knowledge of clinical research, patient values, clinicians’ expertise and the local context within clinical decision making. It is only then, when we understand how knowledge is truly co-construcred that we can promote high quality decision making with some consistency.