Real evidence based healthcare:
- Makes the ethical care of the patient its top priority
- Demands individualised evidence in a format that clinicians and patients can understand
- Is characterised by expert judgment rather than mechanical rule following
- Shares decisions with patients through meaningful conversations
- Builds on a strong clinician-patient relationship and the human aspects of care
- Applies these principles at community level for evidence based public health
- Actions to deliver real evidence based medicine
- Patients must demand better evidence, better presented, better explained, and applied in a more personalised way
- Clinical training must go beyond searching and critical appraisal to hone expert judgment and shared decision making skills
- Producers of evidence summaries, clinical guidelines, and decision support tools must take account of who will use them, for what purposes, and under what constraints
- The research agenda must become broader and more interdisciplinary, embracing the experience of illness, the psychology of evidence interpretation, the negotiation and sharing of evidence by clinicians and patients, and how to prevent harm from over-diagnosis
Individualised for the patient
Real evidence based medicine has the care of individual patients as its top priority, asking, “what is the best course of action for this patient, in these circumstances, at this point in their illness or condition?” It consciously and reflexively refuses to let process (doing tests, prescribing medicines) dominate outcomes (the agreed goal of management in an individual case). It engages with an ethical and existential agenda (how should we live? when should we accept injury?) and with that goal in mind, carefully distinguishes between whether to investigate, treat, or screen and how to do so.
To support such an approach, evidence must be individualised for the patient. This requires that research findings be expressed in ways that most people will understand (such as the number needed to treat, number needed to harm, and number needed to screen) and that practitioners, together with their patients, are free to make appropriate care decisions that may not match what “best (average) evidence” seems to suggest.
Importantly, real shared decision making is not the same as taking the patient through a series of if-then decision options. Rather, it involves finding out what matters to the patient—what is at stake for them—and making judicious use of professional knowledge and status (to what extent, and in what ways, does this person want to be “empowered”?) and introducing research evidence in a way that informs a dialogue about what best to do, how, and why. This is a simple concept but by no means easy to deliver. Tools that contain quantitative estimates of risk and benefit are needed, but they must be designed to support conversations not climb probability trees.
Judgment not rules
Real evidence based medicine is not bound by rules. The Dreyfus brothers have described five levels of learning, beginning with the novice who learns the basic rules and applies them mechanically with no attention to context.The next two stages involve increasing depth of knowledge and sensitivity to context when applying rules. In the fourth and fifth stages, rule following gives way to expert judgments, characterised by rapid, intuitive reasoning informed by imagination, common sense, and judiciously selected research evidence and other rules.
In clinical diagnosis, for example, the novice clinician works methodically and slowly through a long and standardised history, exhaustive physical examination, and (often numerous) diagnostic tests. The expert, in contrast, makes a rapid initial differential diagnosis through intuition, then uses a more selective history, examination, and set of tests to rule in or rule out particular possibilities. To equate “quality” in clinical care with strict adherence to guidelines or protocols, however robust these rules may be, is to overlook the evidence on the more sophisticated process of advanced expertise.Aligned with professional, relationship based care
Real evidence based medicine builds on a strong interpersonal relationship between patient and clinician. It values continuity of care and empathetic listening. Research evidence may still be key to making the right decision—but it does not determine that decision. Clinicians may provide information, but they are also trained to make ethical and technical judgments, and they hold a socially recognised role to care, comfort, and bear witness to suffering.The challenges of self management in severe chronic illness, for example, are not merely about making treatment choices but about the practical and emotional work of implementing those choices.
Adapted from Trisha Greenhalgh, BMJ