The evidence-based health care debate – 2006. Where are we now?

The June 2006 issue of the Journal of Evaluation in Clinical Practice is the ninth in a series of “thematic editions” on evidence-based medicine. (See the list below for introductions to the previous issues.) Below is an excerpt from the introduction to the current issue. [full text by subscription]

Miles A, Polychronis A, Grey JE. The evidence-based health care debate – 2006. Where are we now? Journal of Evaluation in Clinical Practice 2006;12:239-247.

From the introduction:
When an academic in the History of Medicine comes to write a comprehensive account of the nature, characteristics and scale of contribution to human progress of the evidence-based health care movement, there will indeed be a great deal of considerable interest to read. Rarely before, it seems, has there been such fierce and greatly protracted polarization of both scientific and clinical positions as in the last 16 years since the coining of that now severely tired, and almost defunct neologism, ‘evidence-based medicine’ (EBM) (Evidence-Based Medicine Working Group 1992; Polychronis et al. 1996). The Journal of Evaluation in Clinical Practice, over this time, has achieved a pre-eminent reputation in directly ensuring that the necessary debates on the nature of ‘evidence’ took place and, indeed, that they continue to take place. …

We are therefore gratified to commit to the international medical literature the present Part One of the 9th Thematic Edition (Volume 12, Number 3) on the progress of the EBM movement, which augments the previous eight (Miles et al. 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004) and, at the time of writing, we are completing the editing of Part Two of the present Thematic Edition, to be published as the next issue (Volume 12, Number 4). This very large opus having been achieved, we invite contributions to the 10th Thematic Edition for publication in 2007.     DOI Link    June 2006 issue

Here is key article from this issue:

Tonelli, Mark R. Integrating evidence into clinical practice: an alternative to evidence-based approaches. Journal of Evaluation in Clinical Practice 2006; 12 (3), 248-256.

Abstract: Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient.

Previous EBM thematic editions:

Miles A., Bentley P., Polychronis A. & Grey J.E. (1997) The limits of evidence-based medicine. Journal of Evaluation in Clinical Practice 3, 83-86.
Miles A., Bentley P., Polychronis A., Grey J.E. & Price N. (1998) Recent progress in health services research: on the need for evidence-based debate. Journal of Evaluation in Clinical Practice 4, 257-265.
Miles A., Bentley P., Polychronis A., Grey J.E. & Price N. (1999) Advancing the evidence-based healthcare debate. Journal of Evaluation in Clinical Practice 5, 97-101.
Miles A., Charlton B.G., Bentley P., Polychronis A., Grey J.E. & Price N. (2000) New perspectives in the evidence-based healthcare debate. Journal of Evaluation in Clinical Practice 6, 77-84.
Miles A., Bentley P., Polychronis A., Grey J.E. & Melchiorri C. (2001) Recent developments in the evidence-based healthcare debate. Journal of Evaluation in Clinical Practice 7, 85-89.
Miles A., Grey J.E., Polychronis A. & Melchiorri C. (2002) Critical advances in the evaluation and development of clinical care. Journal of Evaluation in Clinical Practice 8, 87-102.
Miles A., Grey J.E., Polychronis A., Price N. & Melchiorri C. (2003) Current thinking in the evidence-based healthcare debate. Journal of Evaluation in Clinical Practice 9, 95-109.
Miles A., Grey J.E., Polychronis A., Price N. & Melchiorri C. (2004) Developments in the evidence-based healthcare debate – 2004. Journal of Evaluation in Clinical Practice 10, 129-142.
 

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