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by Zena Woodley

Evidence Based Medicine - EBM. It's a phrase much beloved by politicians. We're all increasingly familiar with it, but where did it come from, and how did it start?  The philosophical origins, it's claimed, can be found in mid-19th century Paris [see note 1], but it first became common currency in the mid-1990s. It's a means of helping doctors find the information to ensure they provide optimum management for their patients. 

It does this by combining individual clinical expertise with the best external evidence. This external evidence should be a ‘systemised review' of ‘several randomised trials'. For the accuracy of a diagnostic test, ‘we need to find proper cross sectional studies of patients clinically suspected of harbouring the relevant disorder'; for prognosis, what's required is ‘proper follow-up studies of patients assembled at a uniform, early point in the clinical course' of the disease. 

What if there are no randomised trials? Then ‘we must follow the trial to the best external evidence, and work from there'. So - it's a tall order. 

EBM Related to Health Economics

Certainly we are all aware that we should probably do more reading around our chosen subject.  In the mid-1990s, busy consultants had barely an hour a week to keep au courant with the masses of articles that achieve publication. In early 1995, the British Medical Journal [see note 2] decided to collaborate with the American College of Physicians' Journal Club, to produce a journal: Evidence Based Medicine. 

A description of the fining down process is awesome: 6,000 articles on internal medicine published annually are distilled to 300 - and the articles are re-written to one page, rather than the original four or five.  There could be no excuse, trumpeted the BMJ, for any doctor remaining unread!

But well-read or no, even back in the mid-90s there were those who questioned EBM as a fore-runner of health economics. The ‘Socratic dissent' between Socrates and Enthusiasticus is both witty and a ‘nice' taste of what was to come: the author of that BMJ article [see note 3] posits that EBM will be used to shackle doctors and bend them to management will, in the need for health value-for-money.  Indeed, you only have to look at health news to see this is so - the latest outcry coming from Terry Pratchett - http://news.bbc.co.uk/1/hi/health/7561724.stm. 

Real World EBM

I undertook some randomised research on this topic and asked my colleagues on the LIS-Medical discussion list if they could give me examples where EBM had resulted from their work.  The answers came in - and they ranged from the simplicity of the first to the complexity of the last!

• ‘Schools in Highland have water coolers as a result of a search I did for a health visitor'
• ‘We have supplied articles to our Anaesthesia Dept on an urgent basis (e.g.  patient lying on operating table) on more than one occasion. It is very satisfying to know that libraries really do help to save lives!'
• ‘We get a lot of EBM work here, my boss is a clinical librarian and I'm an EBM tutor. We carry out evidence supported ward rounds; the journal clubs are all evidence based and these often have a bearing on the guidelines issued to doctors, nurses and midwives; the evidence from ward rounds will sometimes have made a difference to the treatment the patient receives. As for a direct live patient, that's happened on several occasions. One I can remember from recent times: I was asked to do a search in the morning, I handed the paper(s) over to the surgeons concerned who (following a quick appraisal) then changed the operation they were going to perform on the basis of the evidence gathered by our search'
• This, from a Primary Care Trust colleague: ‘Many of our searches have a direct influence on a patient, as we carry out effectiveness/cost effectiveness literature searches for Exceptional Case Panels (i.e. patients who request treatment not funded under the PCT's clinical priorities policies). Individual patients are directly affected by this in the first instance, but it can also have an effect on future funding and policy making decisions.  We also influence commissioning by producing the evidence on which the budget-holders base their wider service setting decisions (for example breast reduction was funded as proven effective in alleviating back pain in certain specified cases)' 
• ‘The bulk of what I supply tends to be to support study or continuing professional development. However, I do a fair bit of searching to support clinical audit and guidelines, and I have a number of regular requesters who look for evidence to change practice on the ward or in their department, so in that sense the papers I provide do have an impact on patient care. Some examples include:

- The guideline for line blood discard volumes at Great Ormond Street has been changed following a literature search I did

- Analgesia for peritoneal dialysis is under review following a literature search

- I've provided the literature review for a study being designed to establish whether blood taken from a central line is as reliable as that from heel or finger prick in determining antibiotic levels in children

- Cardiac Day Care are using papers I provided to look at distraction techniques to reduce stress and anxiety in children undergoing elective day surgery.'

What is more likely or usual, however, tends to be reflected in this response:

• ‘I've been asked to carry out searches to find evidence on many occasions. I don't always get told that this is why the information is required, but on occasion am told that my searches have contributed to changes in practice.'

And this must strike a chord with many people in health:

• ‘I have a couple of consultants, one in particular, who only come to the library when they want some information to help them solve a patient's problem. For example, a patient had a problem scar following a thyroid operation.  After talking to the consultant I did a search, producing some articles which he read before seeing the patient again.  Sometimes we find the answers he needs and sometimes we don't, but he is a regular customer.'

Patient Access to EBM

It's increasingly difficult to find decent current and full-text articles free of charge.  If you find yourself at a major hospital, my suggestion is to ask where the library is (clarify it's not Medical Records!) and pay them a visit. We are increasingly looking to educate and inform patients (or their relatives/carers). 

The patient information leaflets may not tell you what you want to know about your condition: but it's a certainty that the librarians (and there will still be librarians!) will be able to help you.  They may have broadband PCs they will allow you to access (you may have to pay a small fee for this); they will certainly be able to direct you to reputable health sites. 

Under present conditions, patients are allowed to use a library and, curiously, may have one article copied for them as permitted by their consultant. By all means involve your consultant and his/her team in your desire to learn as much as you wish about your current state of health.  You may even be in a Trust with a clinical librarian (there are around 50 of these in the country; they are rare beasts!)

Using EBM, then, is a slow process of trial and error. I have a personal slant on this: just before I had an operation to re-attach my cornea, I was asked if I would take part in a clinical trial.  It was explained to me that some patients would have certain drops put into their eyes, as it was believed this would aid and speed healing. Others would not. It would be a random assignment. 

It was then I cracked. How, I asked, faced with the evidence that the drops worked, could they not give them to all? And why should I be one of those who - randomly - did not receive them? When I needed my eyes for my job? The researcher talking to me was nearly as distraught as I was. I agreed to proceed, and be part of the trial. My eye healed, and I have continued working.

References

[1]       David L Sackett and others.  ‘Evidence based medicine: what it is and what it isn't.'   British Medical Journal 312, 13 January 1996, pp 71-72.  http://www.bmj.com/cgi/content/full/312/7023/71

[2]       Frank Davidoff and others.  ‘Evidence based medicine.'  British Medical Journal 310, 29 April 1995, pp 1085-1086.  http://www.bmj.com/cgi/content/full/310/6987/1085

[3]       David Grahame-Smith.  ‘Evidence based medicine: Socratic dissent.'  British Medical Journal 310, 29 April 1995, pp 1126-1127.  http://www.bmj.com/cgi/content/full/310/6987/1126

Zena Woodley believes that, in a strange way, all her previous jobs have been preparation for her present post, in the Warner Library of Broomfield Hospital in Chelmsford. She has worked in a whole string of specialist information services, including (among many others) Inmos, Arup, Hydraulics Research Ltd and Verdict, as well as the information services of both Aslib and CILIP.  Now she's been successful in moving the Warner from its former very medical focus more into the centre stream, reminding people that its strapline is ‘The Warner Library: working for ALL'.  In the wider profession, she'll be representing Essex health library and information professionals at county level in the coming year, as well as being closely involved with the East of England Confederations Library & Knowledge Services Alliance.

Other related FUMSI stories:

Technology and Industrial Innovation Resources on the Web: http://web.fumsi.com/go/article/find/2553

Library and Information Show 2008: Information Literacy is Key: http://web.fumsi.com/go/article/use/2924

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