Evidence-based medicine: placing scientific evidence and patient values at the centre of healthcare
Deciding between different treatment options can be a stressful and unnerving time for patients. To make such a decision, patients need guidance and well-founded recommendations from their clinicians. Professor Gordon Guyatt, at McMaster University in Canada, has spent his career in the field of evidence-based medicine, helping clinicians to combine scientific knowledge and evidence summaries with patient values and preferences when supporting individuals to make important healthcare choices.
Talk like an evidence-based medicine researcher
Artificial intelligence (AI) — computer systems that can perform tasks typically done by humans, including problem solving, learning and reasoning
Clinician — a medical professional who has direct contact with patients, rather than being based in a laboratory or academic setting
Decision-aid — a tool designed to support patients in making decisions by providing clear and balanced information about treatment options, including benefits, risks and uncertainties
Diagnosis — the identification of a medical condition such as an illness, injury or infection based on symptoms and other information
Evidence-based medicine (EBM) — an approach that systematically uncovers and evaluates the most recent scientific knowledge to support clinicians and their patients when making healthcare choices
GRADE — a system for presenting evidence summaries and grading the quality of evidence when making healthcare recommendations
Experiencing problems with our health can be scary and unsettling. When we see a doctor, we want to know that the healthcare we receive will be based on the strongest evidence and suited to our individual needs. Much of the progress in modern healthcare is thanks to evidence-based medicine (EBM), an approach to patient care that ensures that our doctors combine up-to-date scientific evidence with our own values and preferences when they recommend treatments. Professor Gordon Guyatt from McMaster University has been a leading voice in the EBM movement since the early 1990s when the field was still in its infancy.
The rise of EBM
In 1990, Gordon coined the term evidence-based medicine, christening a movement that was seeking to change the medical landscape. “At the beginning, if a clinician was deciding between treatment options for a patient, they were using expertise, clinical experience and physiological reasoning,” explains Gordon. “However, nobody was trained to consider rules of evidence that would allow them to distinguish which of the options were more or less trustworthy.”
As time went on, three principles of EBM were developed, and these principles remain at the core of the practice today. Firstly, clinicians need to be aware of the most up-to-date and relevant scientific research about the particular medical condition they are addressing. Secondly, they need to be able to evaluate how trustworthy the evidence is. Finally, clinicians must consider the values and preferences of their patients when making recommendations.
When EBM was first introduced, there were mixed responses. “Before EBM, there was a lot of inappropriate confidence among clinicians, and one of the adjustments they had to make was to recognise all of the uncertainty,” says Gordon. “There was immediate uptake among many leaders in medicine, but there was also very assertive push-back. There is still some resistance out there, but the principles have been very widely adopted.”
The value of patient values
“For patients, there is no right answer as to what choice to make, and evidence does not tell you what to do,” says Gordon. “It’s always evidence in the context of values and preferences.” For example, a patient with advanced cancer may be given the option of chemotherapy, which could prolong their life by a few months or years. However, chemotherapy can be a challenging experience for patients, both physically and emotionally. Patients have to decide which they value more: a longer life or living comfortably.
“Another example that we often use is atrial fibrillation, a condition that causes an irregular heartbeat, increasing the likelihood of a stroke,” says Gordon. “There are anticoagulants that can decrease the risk of stroke by thinning the patient’s blood. However, they can also increase the risk of bleeding.” Patients can discuss their preferences with their doctor to help them decide whether the benefits of stroke reduction outweigh the risk of increased bleeding. “Again, there is no right answer,” continues Gordon. “It is a trade-off.”
Grading the evidence
“If you go back fifty years, there were no formal guidelines to help clinicians make recommendations to their patients,” says Gordon. Over the next couple of decades, organisations began to produce guidelines with the aim of evaluating the trustworthiness of evidence and differentiating between the strength of recommendations. “Strong recommendations are right for almost all patients, whereas weaker, conditional recommendations are value- and preference-sensitive,” explains Gordon.
However, each organisation adopted a different approach. “No one could keep track of anything,” says Gordon. “It was chaos.” So, between 1999 and 2004, Gordon and a group of other researchers developed GRADE: a framework that rates the quality of evidence and the strength of recommendations, and provides evidence summaries. This new system finally allowed clinicians to make informed decisions and take patient values and preferences into consideration.
Reference
https://doi.org/10.33424/FUTURUM569
The GRADE system has now been adopted by over 120 organisations around the world, including the World Health Organization, the UK’s National Health Service (NHS), and UpToDate, an online platform that provides guidance and evidence summaries to clinicians. “My job over the last fifteen years or more has been to help UpToDate be as evidence-based as possible,” says Gordon. “Its evidence summaries can help clinicians understand why the guidelines are recommending treatment A versus treatment B, which helps them in shared decision-making with their patients.”
The problem of time
“When I travel the world talking to clinicians, they always tell me that they don’t have enough time to spend with their patients,” says Gordon. “Clinicians are very busy, so it is difficult for them to keep up with the latest evidence, even with platforms like UpToDate.” These time constraints also make it difficult for clinicians to fully explain evidence and recommendations to their patients.
One solution to this lies in creating more decision-aids, tools that present evidence summaries and options to patients in a clear, understandable way. Decision-aids are available for some medical conditions; however, Gordon is keen for them to become more common.
Artificial intelligence (AI) could also provide solutions. “If AI systems can be trained to quickly provide clinicians with the right guidance and evidence summaries, this could be a major way to reduce the time constraints that every clinician in the world faces,” says Gordon. “A key area of research is exploring how we can use AI to facilitate the efficient delivery of evidence-based care.”
Professor Gordon Guyatt
Faculty of Health Sciences, McMaster University, Canada
Field of research: Evidence-based medicine
Research project: Combining trustworthy scientific evidence with patient values to deliver the best possible healthcare
About evidence-based medicine
Evidence-based medicine (EBM) research focuses on developing ways to identify, review, assess and carry out up-to-date and relevant medical research. EBM researchers create and refine systems that allow clinicians and their patients to access and use this information in their shared decision-making.
Before digital technology was widespread, it was extremely difficult for clinicians to access and assess up-to-date medical information. “To find a particular medical article, you would have to spend hours searching for it in a library,” says Gordon. “EBM was not very realistic at first, but fortunately it coincided with the technology revolution and the internet. Now, the rapidity with which you can get the relevant information is very impressive. It is technology that has made EBM feasible.”
Nowadays, EBM can be a tool for social justice. EBM researchers can use their skills to study whether health funding is being spent in the right places. For example, a recent study1 of the It’s UK’s National Health Service (NHS) found that money spent on new drugs would have provided more health benefit if it had been spent on existing services. “It is important to understand the impact of new interventions and the choices we make, and their impact on the population as a whole,” says Gordon.
“The end goal for EBM is to have every clinical encounter look like this: in two minutes, you can inform the patient about the latest, trustworthy evidence and incorporate their values and preferences to reach a decision that is right for them,” says Gordon. “Whether we will ever get there, I don’t know. But EBM has advanced more quickly than we ever could have imagined.”
1Population-health impact of new drugs recommended by the National Institute for Health and Care Excellence in England during 2000–20: a retrospective analysis Naci, Huseyin et al., The Lancet, Volume 405, Issue 10472, 50 – 6
Pathway from school to evidence-based medicine
To develop a solid foundation, study key subjects such as biology, chemistry and maths at school, before going on to study medicine or a related degree at university.
Considering the values, preferences and circumstances of individual patients is a central element of EBM, so developing an understanding of psychology or sociology can be useful.
Technology has been vital to the development of EBM, and AI may be equally important to its future. Studying technology and AI, alongside topics such as information processing and dissemination, may be helpful.
Approaching people in the field of EBM and seeking out work experience and internships may help you to learn which aspects of EBM you most enjoy.
Explore careers in evidence-based medicine
Learn more about the work of Gordon and his colleagues in the Department of Health Research Methods, Evidence and Impact (HEI) at McMaster University
The Centre for Evidence-Based Medicine has information about the latest research, qualifications, top tips and more.
“One aspect of EBM is using the available evidence to optimise clinical care,” says Gordon. “Another aspect involves actually generating new evidence!” Careers in medical research of many kinds can help you contribute to EBM.
In addition to roles in healthcare settings such as medical practices or hospitals, studying evidence-based medicine could support a career in areas such as dentistry or veterinary science.
Meet Gordon
I’ve never studied a biology course, not even in high school! I never did any basic science; it just didn’t interest me like other things did. My university major was in English literature, and my minor was in psychology. However, part way through university, I decided I was interested in medicine. McMaster University happened to be in my home town, and had the only medical school accepting students without a science background. It was a totally revolutionary medical school with problem-based, self-directed learning, so that was wonderful for me.
I switched to medicine because I wanted to do something practical. I wanted something concrete that would allow me to say, “Okay, at the end of the day, I know I helped somebody in some particular way.”
I think what I love most about my job is supervising students. I am lucky to work with wonderful colleagues and students who I get along with, and who share my mission. Seeing how these students develop and helping them build careers for themselves is a constant joy.
Being able to get excited about things and to be passionate, and being able to devote large amounts of time, energy and dedication, has enabled me to lead a successful career. I was fortunate that my background in English literature came in handy. A huge part of succeeding in science is being able to communicate, and it’s turned out that I’m a very good communicator. That has been enormously helpful.
I’ve been fortunate to work in environments where there are lots of talented people who I can go to for help. I’m very ready to acknowledge when I don’t know something and when I’m wrong and need to change course.
I am a very serious mountain biker, and I like challenging rides. If you put me next to a casual rider forty years younger, I could go up a hill faster than they can! I’ve been doing it a long time, but, if anything, my enthusiasm and my readiness to take on challenges has increased.
Gordon’s top tips
1. Find out what excites you, what feels good. That is the direction
to follow. Look around for what’s going to be fun and exciting, and what you’re going to love.
2. Stay alert for opportunities. Success is a series of good fortune,
but you’ve got to be on the lookout for the things that might help you.
Do you have a question for Gordon?
Write it in the comments box below and Gordon will get back to you. (Remember, researchers are very busy people, so you may have to wait a few days.)
Find out how you could get involved in medical research:
www.futurumcareers.com/inspiring-high-school-students-in-clinical-research
0 Comments