Negotiating the barriers to the application of evidence based medicine

It’s been over 16 years since the notion of EBM was popularized. You’d think in those 16 years we’d have come a long way. What once took an entire afternoon to find in the archives of a traditional print library (remember the Index Medicus?) can now be accessed in mere moments on line. Yet, the penetration of best evidence into clinical practice remains low, ranging from 10% to 50% in surveys. In spite of all the progress we’ve made there remain barriers.

In the February 15 installment of American Family Physician’s series on this topic Mark H. Ebell, MD, MS discusses some of these barriers. One of the most important barriers, he says, in spite of the improved speed that internet technology has delivered, is still time. Filtered resources (secondary sources) help save time by removing from the end user the steps of searching and critical appraisal. That’s a mixed blessing. In some situations there’s no substitute for searching and critically appraising the primary sources. Over reliance on secondary sources may lead to a loss of these skills. Secondary sources vary in quality and some are very expensive. It’s a work in progress.

Some of the barriers, Ebell points out, are cultural. One cultural barrier he didn’t mention is that of patients’ perceptions (or misperceptions) about searching for answers at the point of care. Some patients admire and respect the doctor who goes to the trouble to look up answers. Others, thinking that doctors should “know it all”, may look askance. Doctors should be concerned about patients’ perceptions. Should they look up answers in front of the patient or should they leave the room?

Perhaps the ultimate advance to help improve penetration of evidence into practice is the embedding of best evidence pathways into computerized physician order entry systems. This technology is in its infancy.

A major downside to all these advances is that they de-emphasize background reading, pathophysiologic rationale, critical appraisal and judgment. Sixteen years after the launch of the EBM movement our biggest challenge moving forward is to increase the application of EBM to everyday practice without diminishing the physician’s role.