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INTRODUCTION

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Incredibly, some scientifically educated medical school graduates still see evidence as inferior to intuition and experience: those are the ones who give me chills.

Dr Harriet Hall

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CASE: INTRODUCTION

Your patient is Mrs J, a 55-year-old woman with knee pain. She complains of pain, stiffness and mechanical symptoms consistent with a meniscal tear. She has had an X-ray in which the radiologist notes degenerative changes consistent with osteoarthritis.

Question

Should you recommend surgical or non-surgical management?

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WHAT IS EVIDENCE-BASED PRACTICE?

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Evidence-based practice (EBP), also known as evidence-based medicine (EBM), is the dominant paradigm under which healthcare professionals across the world are now expected to practice. We use the term ‘practice’ to avoid the ambiguity in the word ‘medicine’ (which is sometimes used to refer only to the work of medical doctors). Clinicians and researchers from McMaster University in Canada in the 1980s and 90s are credited with developing the ideas behind EBP and championing the movement. The most commonly used definition comes from David Sackett1 and it highlights the integration of three elements: best available evidence from well-conducted and relevant scientific research, clinical expertise, and patient values and preferences2 (Fig. 2.1).

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Figure 2.1

Schematic illustration of how clinical skills, evidence from research and patient desire should overlap to provide the ‘quality decision’ for the patient

*evidence-based practice

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Evidence-based practice should provide better patient outcomes than so-called ‘eminence-based practice’ whereby the opinion of the clinician alone defines an optimal management decision. In the caricature of eminence-based practice, inappropriate and outdated methods and practices were perpetuated from senior to junior clinicians and personal clinical experience weighed more heavily than quality research evidence. We acknowledge that many clinicians provided wonderful evidence-based practice before the term ‘evidence-based practice’ was coined.

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Today, healthcare systems and consumers expect practice to be grounded in science. This mirrors the progression to today’s technology-supported world from a society based on semi-mystical beliefs and paternalism. EBP, however, asks more than just acceptance of a scientific world view; it requires explicit understanding and integration of the three elements.

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WHY IS THE EVIDENCE-BASED PRACTICE CONCEPT CONTROVERSIAL?

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Superficially, the principles of EBP are straightforward and few argue that it represents a superior model to a paternalistic opinion-based medical model. In general, clinicians have positive attitudes towards EBP. Yet debate over the merit of EBP occupies space in numerous high-profile medical journals. In particular, there is contention when research evidence conflicts with clinical opinion that is based on observation and recall of patient outcomes.

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PRACTICE PEARL

To accept the primacy of relevant high-quality research evidence requires acceptance of the flawed nature of one’s own observations and recollections.

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Also, engagement with EBP requires the clinician to be continually ...

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