Accounting for EBM: Notions of evidence in medicine

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Abstract

This paper takes as a focus of anthropological enquiry the set of techniques and practices for the appraisal and clinical application of research evidence that has become known as evidence-based medicine (EBM) (or, more recently, evidence-based health care). It first delineates and classifies the criticisms of EBM emerging from within the health professions. It then charts the evolution of EBM in responding to these criticisms and uncovers its character as a pedagogical innovation aimed at transforming clinical practice. It identifies EBM as an indeterminate and malleable range of techniques and practices characterised not by particular kinds of methodological rigour, but by the pursuit of a new approach to medical knowledge and authority. It situates this characterisation within a contemporaneous political and economic climate of declining trust and growing accountability. This analysis provides a basis from which to consider the notions of evidence implicit in EBM itself and also in the qualitative social sciences, including anthropology, which not only critique but also contribute to these notions themselves. Finally, the paper considers possible future trajectories for EBM with regard to the incorporation of cultural and structural dimensions of health and the inclusion of qualitative material in the evidence base.

Section snippets

Introduction: A pedagogical and autobiographical trajectory

My personal impetus for beginning to think and write about notions of evidence has been my dual institutional position in two academic departments of public health since 1991 as both observer of the rise of evidence-based medicine and as participant, required (as is usual in multidisciplinary environments) to defend and promote ethnographic and other qualitative approaches to research. Here, I gloss ‘evidence-based medicine’ (henceforth EBM) loosely as referring to the demand that clinical

Critiques of EBM: A typology of alleged limitations

While what ‘EBM’ is continues to be negotiated and broadened—a point central to the argument of this paper—the limitations rather than the benefits of EBM have been the subject of fervent and often polemical debate in the pages of many health practitioners’ journals. Many mainstream medical journals have published articles on the topic, while the Journal of Evaluation in Clinical Practice has emerged as a major site for critique with an annual thematic issue on the EBM debate. I undertook a

Encompassing objections: The evolution of EBM

The previous section provided a brief orientation to major categories of criticism levelled at EBM. As each type of putative limitation has been identified in commentaries and papers, each has progressively been accommodated within the parameters of EBM itself. My review of the literature suggests that criticism has characteristically been countered not by rejection, contestation or entrenchment, but by incorporation. This assimilationist response is fairly characteristic of the way in which

Models of and models for medical practice: education and revolution

The rise and rise of EBM in the UK, as elsewhere, can be seen perhaps most clearly in its gradual entrenchment within the medical curriculum (Demar, Glasziou, & Mayer, 2004; Sinclair, 2004; Straus & Jones, 2004). A study of UK medical schools in 2001 found that most include critical appraisal in the curriculum and examinations for postgraduate training (Alderson, Gliddon & Chalmers, 2003), while a 1998 survey of the UK medical Royal Colleges (which licence clinicians to practice at consultant

Accountability and the moral loading of EBM debates

It is beyond the scope of this paper to consider in detail the broader institutional and social environmental structures and historical circumstances within which EBM has been formulated and propagated. However, lest it appear that I am suggesting that EBM's current institutionalisation within several national health systems can be accounted for solely in medical historical terms, it is important briefly to indicate the political and economic dimensions of the EBM critiques discussed above.

What counts as evidence in EBM?

My original intention in examining critiques of EBM and responses to them was to explore underlying notions of what actually constitutes ‘evidence’ within EBM, beyond the definitions provided by exponents. The quantitative, essentially epidemiological definition of evidence used in EBM was most often identified as problematically restrictive in critiques classified as type 5 in Table 1—failure to consider patient views. For although in evidence-based clinical practice the starting point for

Considering qualitative ‘evidence’: The example of anthropology

Ethnographic and other forms of anthropological research, for example, can plainly produce evidence just as much as the next RCT. The problem lies, rather, in the standards and criteria taken as authoritative in assessing the admissibility and veracity of such evidence. In medical education and practice, EBM reasonably requires the provision of tools for appraising and interpreting evidence and these are currently formulated according to epidemiological criteria. In consequence it would seem

Future trajectories for EBM: Structural influences and contextual dimensions

The main reason for taking seriously whether anthropological and other qualitative material can, by its nature, be admitted into evidence within health research, is to correct, or contest, the composition of the current evidence base. What strikes many social scientists as obviously lacking in descriptions of research evidence as represented within EBM (for example Fig. 2), is a place for—or even acknowledgement of—social structural influences and social, cultural, political and economic

Acknowledgements

I am grateful to participants in the 2003 American Anthropological Association panel on Evidence-Based Practice that provided the initial impetus for this paper and particularly to my discussants, Robert Hahn and Deborah Gordon. I also thank Libby Bogdan-Lovis, George Davey Smith, Elisa Gordon and the Social Science and Medicine manuscript reviewers for their useful comments on an earlier draft of this paper.

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