The rise of “evidence-based medicine” (EBM) has been described as meteoric (Zimerman, 2013). Although the term first appeared as the title of an editorial in 1991 (Guyatt, 1991), a year later it was described as a “paradigm-shift” and by 1993, the “era” of EBM was being discussed (Zimerman, 2013). The evidence-based initiative could now be considered an accepted standard in healthcare generally with terms such as “evidence-based practice”, evidence-based healthcare”, and “evidence-based decision-making” being common.

From the outset, EBM was conceptualized as the integration of the best available evidence with clinical expertise. Sackett, Rosenberg, Gray, Haynes, and Richardson (1996, p. 71) defined EBM as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research”. With regards to clinical expertise, the “identification and compassionate use of individual patients’ predicaments, rights, and preferences” was considered important (Sackett et al., 1996, p. 71). These facets of decision-making have been explicitly delineated as four components in the JBI model of evidence-based healthcare: the best available scientific evidence; patient preferences; the context of healthcare; and the judgement of the clinician (Pearson, Jordan, & Munn, 2012).

Ironically, despite the enthusiasm with which the evidence-based movement has been embraced, evidence indicates that the current approach needs improvement. Inappropriate healthcare, for example, is a widespread global phenomenon involving the underuse of simple and inexpensive interventions and the overuse of familiar, lucrative, but ineffective services (Saini, Brownlee, Eslhaug, Glasziou & Heath, 2017) that wastes billions of dollars every year. A variety of factors are no doubt responsible for the manifestation of inappropriate care, but the four elements identified by Pearson et al. (2012) are key.

Clearly, central to the evidence-based era is evidence. The way in which evidence is conceived, however, has a strong impact upon the importance attributed to context, patient preferences, and clinician judgement. Generally, in healthcare settings, the most credible form of evidence is regarded as that provided by randomized controlled trials (RCTs). The RCT is regularly assigned “gold standard” status as the pre-eminent method for demonstrating treatment or program effectiveness and has been described as “perhaps the most important discovery of modern medicine” (Jureidini & McHenry, 2020, p. 99). Even though assigning a gold standard to a particular methodology has been criticized as erroneous (Jadad & Enkin, 2007), the RCT as a gold standard remains the prevailing attitude in health.

Paradoxically, it is the very features of the RCT design that makes it a robust and rigorous research method, that also make it problematic for the generation of useful evidence in health and other settings. The fundamental purpose of the RCT is to demonstrate a causal link between an intervention and its effectiveness (Carey & Stiles, 2016). To use RCT methodology, therefore, is to assume that it is the intervention that creates the effect. From this perspective, “evidence” is a property of the program and can be transported from one setting to another (Carey, Fauth, & Tremblay, 2020). A key feature of the RCT is the extent to which important variables are tightly controlled but it is precisely this strength of RCTs that means their contexts are very unlike typical healthcare settings. 

Ascribing causality to the intervention or service also has the unfortunate consequence of positioning the service provider and service recipient as mere conduits of the intervention. An intervention’s outcomes, however, are co-created by service providers and service recipients using the resources of the intervention to produce the effects they desire (Carey et al., 2020).

Assigning RCTs, and therefore the evidence they generate, as “gold standard” helps to explain why other important aspects such as context, patient preferences, and service provider expertise are not prioritized as highly as they otherwise might be. It becomes even more problematic when one appreciates the judgements that might be involved in determining what makes evidence “best” evidence as well as the inherent cognitive biases that are an inevitable feature of all clinician decision-making.

For many reasons, therefore, if health and other services are to be improved, it is not enough to rely only on evidence generated in different contexts. It needs to be seen as imperative that service providers use the data that they routinely collect in the course of their service provision to inform their decision-making. Policy change is desperately needed to create a culture of evidence-building practices that could co-exist alongside evidence-based practices. Evidence generated in research settings could help to inform decision-making but ongoing reasoning about the service being provided should be guided by the data being generated during service provision.

A study in the US found that health and education service providers highly valued systems of ongoing monitoring and evaluation for enhancing program effectiveness as well as improving engagement and impact (Carey et al., 2020). As important as evaluation was regarded to be, however, participants reported that it would quickly disappear from their services if policy imperatives didn’t demand it and they weren’t funded for it. In this study, many of the participants were involved in projects funded by the US Substance Abuse and Mental Health Service Administration which typically allocates 15% to 20% of a program’s budget to the evaluation of the program. Policy such as this should become standard so that service providers in any setting are required to use the data that they generate to determine effectiveness and efficiency.

The evidence-based era has demonstrated that research evidence is necessary but not sufficient to ensure that the provision of programs and services is effective and efficient and addresses individual and community priorities from the perspective of the recipients rather than the providers of those services. Policy reform is urgently required to insist that all service providers not only base their practices on evidence but also engage in evidence¬-building activity so that, on an ongoing basis, service recipients are receiving the best possible program or intervention to help them live a life they value.

References

Carey, T. A. (2017). Patient-perspective care: A new paradigm for health systems and services. London: Routledge. https://doi.org/10.4324/9781351227988

Carey, T. A., Fauth, J. M., & Tremblay, G. T. (2020). Rethinking evaluation for improved health outcomes: Implications for remote Australia. American Journal of Evaluation, 41(2), 234-254. https://doi.org/10.1177/1098214018824040

Carey, T. A., & Stiles, W. B. (2016). Some problems with randomized controlled trials and some viable alternatives. Clinical Psychology & Psychotherapy, 23(1), 87-95. https://doi.org/10.1002/cpp.1942

Guyatt, G. H. (1991). Evidence-based medicine. ACP Journal Club, 114(2), A16. https://doi.org/10.7326/ACPJC-1991-114-2-A16

Hudson, S. (2016). Mapping the Indigenous program and funding maze. Sydney: The Centre for Independent Studies. ISBN: 9781922184726. https:// www.cis.org.au/app/uploads/2016/08/rr18-Full-Report-High-Res.pdf

Jureidini, J., & McHenry, L. B. (2020). The Illusion of Evidence-Based Medicine: Exposing the crisis of credibility in clinical research. Adelaide, SA: Wakefield Press.

Pearson, A., Jordan, Z., Munn, Z. (2012). Translational science and evidence-based healthcare: A clarification and reconceptualization of how knowledge is generated and used in healthcare. Nursing Research and Practice, 2012, Article ID 792519. https://doi.org/10.1155/2012/792519

Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence Based Medicine: What it is and what it isn’t. BMJ, 312, 71-2. https://doi.org/10.1136/bmj.312.7023.71

Saini, V., Brownlee, S., Elshaug, A. G., Glasziou, P., & Heath, I. (2017). Addressing overuse and underuse around the world. The Lancet, 390(10090), 105-7. http://dx.doi.org/10.1016/S0140-6736(16)32573-9

Zimerman, A. L. (2013). Evidence-based medicine: A short history of a modern medical movement. American Medical Association Journal of Ethics, 15(1), 71-6. https://doi.org.10.1001/virtualmentor.2013.15.1.mhst1-1301