Monday, July 10, 2017

Evidence-based vs eminence-based practice

Western “evidence” cannot take the place of Indian “eminence”

Medicine has undergone a generation change with the technology savvy younger doctors now coming to the forefront and taking over from the older doctors. These young doctors have the latest information at hand about the happenings (researches) in the field of medicine.

Evidence-based medicine has become the norm in clinical practice today.

In an editorial published in the BMJ in 1996, Dr David L Sackett and coauthors defined EBM as “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”.

Evidence-based practice (EBP) incorporates clinical expertise or skill with best available clinical evidence and patient expectations and values. It is a dynamic process, which is continually changing because new studies are being published everyday adding to the existing body of evidence.

Even the law requires evidence. Bolam test, which evaluates the standard of care and decide on the adequacy of information disclosed when deciding cases of medical negligence, is based on experience “… is not guilty of negligence if he has 'acted in accordance with a practice accepted as proper by a responsible body of medical man skilled in the particular act”. And, the adequacy of information disclosed to the patient for a valid consent, as per Bolam test, must be in accordance with the practice accepted at that time as considered proper by a responsible body of medical opinion.

Whereas, the case of Montgomery v Lanarkshire Health Board decided by the UK Supreme Court is based on evidence. Doctors in UK are now required to furnish information about all possible risks associated with a particular treatment, however rare, to the patient “…to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments”.

Evidence-based medicine relies on scientific evidence derived from studies, which can be case reports, case series, case-control studies, RCTs, systemic review, meta-analysis, observational, retrospective. The methodology of each is different, the sample population is different. The population differs in terms of ethnic groups, geography, culture, phenotype, etc. Hence, data cannot be extrapolated from one population to another population not included in the study, especially of a different ethnic group.

For this reason, international guidelines are not suitable for India. The heterogeneity of population, different phenotype and cultural beliefs and practices need to be considered. For example, take the case of TB. Western data cannot be extrapolated to our population with TB. We have only recently started to come out with India-specific guidelines.

‘Eminence-based practice’ is based on clinical experience and wisdom of a person of eminence gathered over many years of clinical practice. Personal experience is also data, which is unpublished. Where Indian data is lacking, experience will count.

There will always be a place for “eminence-based” practice. Even if local evidence is available, but cannot be applied to the patient or the patient is a complicated case, clinical experience prevails over evidence.

So does, evidence-based practice trump eminence-based practice?

No. None can supersede the other. Both need to coexist with their individual benefits and limitations.

You need to be updated with the latest technologies and developments in medicine to give the best possible care to your patient, yet, the value of experience can never be discounted or disregarded. Eminence-based practice runs the risk of personal bias, which is omitted in evidence-based practice.

This scenario can be likened to the age-old debate of young (evidence) vs old (eminence), black hair (evidence) vs gray hair (eminence), experience (eminence) vs enthusiasm (evidence). There is no clear winner, no clear loser.

Maa Saraswati, the Goddess of Knowledge, wisdom and learning. She is shown holding a small Vedic book in one hand, a rosary in the second and a large Veena in the other two. The small Vedic book indicates that reading books is important but this alone is not sufficient to gain knowledge. The small rosary also denotes that one needs to read a subject repeatedly. The main tool, the large Veena represents practice or Abhyas or experience or “eminence”.

The practice of medicine is an art (eminence) based on science (evidence). Hence, the clinical expertise of the doctor and the best available evidence should be considered together for best patient outcomes. 

Dr KK Aggarwal
National President IMA & HCFI

No comments:

Post a Comment