Evidence-based medicine has been called “cookbook medicine” by some of its more vocal critics. This implies that evil faceless organisations like Cochrane aim to turn all healthcare workers into mindless automatons who blindly follow dictums derived solely from scientific evidence. I hope it doesn’t surprise many in that this has never been the aim of Cochrane, or EBM in general, nor will it ever be. EBM, or EBP if you prefer the term ‘practice’ rather than the more vague ‘medicine’, is a belief system that rests on three pillars (cf. five in Islam). The EBM pillars are: 1) best available scientific evidence (i.e. the purview of Cochrane and yours truly), 2) clinical experience and 3) patient preferences and values. So, the main gist is that evidence doesn’t matter – no matter how scientific – if we don’t have a clinician at hand to interpret it for the benefit of a particular patient equipped with a particular set of values. For example, in a situation where two very similar patients have the same condition, one might wish to achieve speedy return to work whereas the other might rather avoid pain at all cost. The clinician would then use his or her judgment to identify the best course of treatment for both based on experience and what us science types have to offer. However, let us now leave the two pillars of clinical experience and patient preferences to be explored in future posts so that we can chew the first a bit more.
Now, the evidence bit in EBM is often understood to mean results of systematic reviews (a fancy type of research). Inasmuch as they offer an abstracted truth devoid of context (see my earlier post on mathematical ghosts) they still need to be interpreted for use in particular circumstances. This doesn’t always have to be done for every single patient by every single clinician separately. Think of the usefulness of reinventing the wheel for every drive. Often the thinking behind the interpretation and application of evidence can be written down and made use of by many. On a population level this means drafting guidelines. However, it is important to note that when scientific evidence is freely available one does not need to wait for formal committees to grow their beards long enough to formulate official guidelines. Especially when even supposedly professional guideline developers can do a really poor job (see previous post by Margot Joosen). In fact, all informed people and communities should participate in making sense of and advocating for the use of research to back up health decisions. In the end it affects the quality of care they receive.
And here I could go on jabbering more scientifiquese but it’s much more fun to illustrate the issue with a thoroughly silly example. Not having exhausted my enthusiasm for employing those proud knobbly-foreheaded humanoid warriors known as Klingons (habitants of the fictional Star Trek universe), I rallied round their honorary cultural attaché Felix Malmenbeck. I ask you to kindly play along as Felix and I present an entirely genuine (ahem) internal memo we intercepted and translated from the original Klingon (see my earlier post for going the other way). Can you see the approach angle taken here? Do you see how the interpretation of the evidence is not derived from the evidence itself but something to do with the context and the target audience?
Are you brave enough to read the Klingon OSH memo?
The point here is simply to show how a particular population might interpret scientific evidence for the benefit of its constituents. In other words, a brutal war-hungry humanoid race might even go to such extremes as stressing the importance of maintaining their army in combat readiness regardless of the cost to individual troops. So the really pointy end of the point (really stabbing it deep here) is that the evidence itself is not a recommendation. There has to be an active someone doing the interpreting of scientific evidence and this someone will always have an agenda. We can only hope that on Earth the agenda is to improve health and safety!
Also, there are no cookbooks in the Cochrane Library.
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- Parantainen A, Verbeek JH, Lavoie MC, Pahwa M. Blunt versus sharp suture needles for preventing percutaneous exposure incidents in surgical staff. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD009170. DOI: 10.1002/14651858.CD009170.pub2.
- Nieuwenhuijsen K, Faber B, Verbeek JH, Neumeyer-Gromen A, Hees HL, Verhoeven AC, van der Feltz-Cornelis CM, Bültmann U. Interventions to improve return to work in depressed people. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD006237. DOI: 10.1002/14651858.CD006237.pub3.