The March 2001 report from the Institute of Medicine, “Crossing the Quality Chasm: A New Health System for the 21st Century,” lists ten rules for redesign of the health system. One of these rules is that decisions about care should be based on the best available scientific evidence, with the highest form of evidence usually taken as a well-performed randomized clinical trial. That is, clinicians should practice evidence-based medicine, both to provide the highest quality care for individual patients and to decrease illogical variations in practice.
The definition of evidence-based medicine in widespread use came from Dr. David Sackett: “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of people.” But how does a clinician translate evidence from the literature into practice?
Dr. Stuart Barton, a general practitioner in the UK (formerly clinical editor of the BMJ publication, Clinical Evidence), presents a five-step model for making evidence-based clinical decisions.
- Recognize that the gap between one’s knowledge and the knowledge needed to answer the relevant clinical question requires consultation of another source.
- Formulate a specific question to be answered by the consulted source.
- Search for the relevant information, which might include print or electronic sources.
- After consultation, a specific answer to the question must be formulated.
- The answer must be applied to a care decision.
The steps pose some common difficulties for a busy practitioner. Time and the availability of sources may be significant barriers. Further, moving from a vague question to one that can actually be answered by the consultation may be difficult or time-consuming. Clinicians routinely require quick and practical answers to their clinical questions, answers that can be easily applied to the context of care of an individual patient. And synoptic material may fail to provide the specificity needed to formulate an answer that can be applied in practice.
Clinical guidelines have often been offered as the answer to providing an evidence base for practice. But guidelines are usually not as question-driven as would be helpful, and do not always account for comorbidities and the complexities inherent in individual patients. The most useful guidelines are therefore question-based, contain a summary of their recommendations, address both benefits and harms of treatments, address the validity of the evidence on which they are based, comment on their generalizability, and provide general background and context for the situations addressed.
Guidelines that are formulated in this manner will go a long way toward increasing the application of evidence to clinical practice.
