Bumps in the Road to IM/EBHC

What is Evidence-Based Medicine?

“An acknowledgment that there is a hierarchy

of evidence and that conclusions related to

evidence from controlled experiments are

accorded greater credibility than conclusion

grounded in other sorts of evidence.”

-- Brian Hurwitz. BMJ 2004;329:1024-8.

What’s so hard about that?

Bumps in the road

• Financial

disincentives

• Organizational

constraints

• Perception of liability

• Patient expectations

• Standards of practice

• Opinion leaders

• Medical training

• Drug companies

• Uncertainty

• Competence

• Need to “do

something”

• Information overload

Barriers and solutions

• Why are some people resistant?

• How can we “bend them to our

will”?

Barrier: Difficulty finding the evidence

• Too hard to round up all of the

information

• “Satisficing” -- acceptability of “an

answer,” not necessarily “the

answer”

• It’s impossible to “keep up”

Solutions

• Use a “clinical awareness system” for handling your information needs– Keeping up (foraging):

• Daily InfoPOEMs, ACP Journal Club

– Answering questions (hunting)• Clinical Evidence• InfoRetriever • Best Evidence/ The Cochrane Library

Barrier: “Those results don’t apply”

• “All studies are flawed”

• “All patients are different”

• “You can find a paper to support

anything”

Solution

• All studies have flaws,

but not all flaws are “fatal”

• Truth is a “probability”

– All patients are different, but the goal of

medicine is to try what’s most likely to

work most of the time

Barrier: Tradition

• From the apprenticeship system of

medicine

• The seven deadly words:

– “We’ve never done it that way before”

• We’ve always used “evidence”

Solutions

• “Evidence” in the traditional sense does

not equal “Outcomes” (DOE vs POEM)

• Introduce a culture of questioning and

continual change

• Make change easier by changing

processes

Barrier: Perceived loss of Autonomy

• “Guidelines are cookbook medicine”

• “Anyone can practice medicine with

EBM”

– computers can see patients

Solutions

• Good cooks know the recipes and “spice to taste”

• Clinical freedom implies doing what’s best, not doing whatever one pleases

• EBM provides the best information for one to form the best decisions; it doesn’t provide the decisions themselves

Barrier: It scoffs at Clinical Experience

• If it’s not from a clinical trial, it’s not

valid

• Ignores the “art” of medicine

• “How do I know it works? I know

because I’m older than dirt . . .”

Solution• Goals of medicine: Relieve/prevent

suffering; maintain/provide hope; prevent, treat, or cure disease

• The science of medicine: knowing the best way to prevent, treat, or cure disease (EBM can address this aspect)

• The art of medicine: Determining, using intuition, experience, and judgment, what patients need the most

• Clinical jazz = science + art

Barrier: Statistics scare me

• Too many numbers in EBM

• “Medicine is about people, not statistics”

– “No patient is a likelihood ratio”

• Photonumerophobia: The fear that one’s

fear of statistics will come to light (D.

Sackett)

Solutions

• Medicine is all about likelihood and probabilities

• EBM attaches numbers to “highly likely”, “cannot be ruled out”, “unusual”, and other words used to describe probabilities

Barrier: “Saying Mass in English”

If everyone can have access to the

“liturgy,” (the knowledge of

medicine) what is the role of the

“priests” (teachers)?

Solutions

The Priests still have to:

– Interpret the medical literature

– Teach the art of medicine

– Teach how to think (vs. what to know)

Barrier: “Me” vs. “Them”

• “Someone is always trying to change

me”

• Studies are done “out there”, which

is different from “in here”

Solution• “For most doctors, change is virtually a

routine part of life . . . The alternative to controlling the process of change is to be controlled by it, and in dramatic cases, to experience professional or personal

collapse.” • “One of the greatest pains to human

nature is the pain of a new idea.”

Sales/Marketing

Three types of people you will encounter:– Customers- those who are interested in

your product– Visitors- those who are there because

someone told them they should, but they are uncertain

– Complainers- those who are there to thwart your efforts

Inducing Change: Semmelweis Revisited

“Insult your enemies, accuse your superiors of causing the deaths of mothers, actively join academic political factions, abandon your friends, refuse to publish, but when you do so write incomprehensibly, use public humiliation and haranguing to change behaviour, and be arrogant and angry yourself. This will not work every time.”

• Qual Saf Health Care 2004;13:233–234.

Sales/Marketing

• Use your time and effort working with your customers and enlightening the visitors

• Don’t waste valuable energy on complainers, despite feeling the urge to do so

• Some early adversaries can become your greatest allies

Suggestions/Solutions/Pearls

• Start a journal club but don’t call it that– “Is it true?” rounds

– Information Mastery

– “Hagy” rounds (after chair, to gain his/her support)

• Chair commitment to teach curriculum– “Time” for teaching and planning

• Watch out for “submarine attacks” from threatened

faculty or other clinicians– “EBM is good, but out in the trenches . . .”

– “I’ve practiced all my life without EBM . . .”

Suggestions/Solutions/Pearls

• Work on assimilating outside faculty– CME evaluation form

• Look for external support/endorsement/funding– Dean– Managed care organizations

• Support Group/ Networking