Chapter 28.5: Evidence-Based Practitioners and Evidence-Based Care

Introduction

Top-quality health care implies the practice of medicine that is consistent with the best evidence (evidence-based health care). An intuitively appealing way to achieve evidence-based practice is to train clinicians who can independently find, appraise, and judiciously apply the best evidence (evidence-based experts). Indeed, our fondest hope for this book is that it will help you become an evidence-based expert. The following discussion, however, illustrates that training evidence-based experts is not, by itself, an optimal strategy for ensuring patients receive evidence-based care.¹

In this chapter, we acknowledge the challenges in developing expertise in evidence-based medicine (EBM). Next, we highlight an alternative approach to providing evidence-based care, which is training clinicians who can use evidence-based summaries and recommendations; we call such clinicians evidence-based practitioners. We then acknowledge the limitations of this strategy and suggest a solution. Finally, we present some of the reasons you might wish to pursue development of more advanced EBM skills, although these skills are not prerequisites for practicing EBM.

Becoming an Evidence-Based Medicine Expert Takes Time and Effort

The skills needed to provide an evidence-based solution to a clinical dilemma include precisely defining the problem, conducting an efficient search to locate the best evidence, critically appraising the evidence, and considering that evidence—and its implications—in the context of patients' circumstances and values. Although attaining these skills at a basic level is relatively easy, developing the expertise to allow efficient and sophisticated critical appraisal and application to the individual patient requires (as with developing expertise in any area) time, effort, and deliberate practice.

The advanced topics chapters of this book highlight the challenges of becoming an EBM expert. You must have a deep understanding of and be alert to violations of the principles of valid scientific inquiry (issues such as stopped early trials, analyzing according to the intention-to-treat principle, and selective reporting of outcome variables). In addition, you must be aware of how even studies at low risk of bias may mislead (note the strategies to avoid being misled in Chapter 13.3, Misleading Presentations of Clinical Trial Results, and additional issues, such as the use of surrogate end points and composite end points). In short, you must be motivated to continue learning about new developments in clinical research methods and to explore their effect on clinical decision making. Becoming an EBM expert is gratifying, but it is not for everyone.

All Clinicians Can Become Evidence-Based Practitioners

Considering the challenges of becoming an EBM expert, it comes as no surprise that most internal medicine residents at McMaster University, even in a program explicitly committed to systematic training in EBM,² are not interested in attaining an advanced level of EBM skills. Our trainees' responses mirror those of general practitioners in the United Kingdom, who often use evidence-based summaries ...