Course Level: Intermediate
Format Requirements: A combination of didactic review of information, and interactive critical review and discussion of case studies and interventions to improve evidence-based practice. Requires only background familiarity with evidence-based medicine.
Background: Evidence-based medicine (EBM) has gained increasing acceptance as an approach to improve clinical decisions. Briefly, the EBM process entails defining decisions of interest, systematic search to find the best clinical research about the benefits and harms of plausible decision options, critical review of that literature to estimate the options’ benefits and harms, and application of the results to decisions which are also informed by patients’ values, preferences, and biopsychosocial context. However, considerable evidence suggests that physicians rarely make decisions according to the EBM ideal and many attempts to change physician behavior to make it more evidence based have failed. This course will examine reasons physician practice at times fails to adhere with EBM principles and explore possible ways to promote EBM-based practice.
Description and Objectives: We will briefly review evidence that practice is often not evidence-based, and the history of interventions intended to make it more so, which generally have not been very successful.
To stimulate thought about whether all relevant barriers to evidence-based practice have been recognized, we will focus on a particular problem: the recognition and treatment of depression in primary care. We will discuss possible barriers to adherence to evidence-based guidelines for this problem and review the latest clinical evidence to develop alternative hypotheses about why physicians fail to follow them.
This will lead to consideration of problems in guideline development and content leading to untrustworthy guidelines that do not inspire adherence. We will then discuss external influences designed to further vested interests that may interfere with evidence based practice, including manipulations of the design, implementation, analysis, and dissemination of clinical studies, outright suppression of research, manipulation of education, especially involving stealth marketing, deception used in conventional advertising and marketing, and perverse incentives.
Finally, we will propose some possible solutions, based partially on review of recent IOM reports on conflicts of interest in medicine, and development of trustworthy guidelines.
Objectives - to understand
- evidence that physicians fail to practice according to the evidence
- how deficiencies in guideline development may adversely affect evidence-based practice
- how external influences from vested interests may mitigate against evidence-based practice
- current proposals to improve guideline development, and ameliorate external influences to encourage evidence-based practice