Has the History and Philosophy of Evidence-Based Healthcare (EBHC) Helped EBHC?
The authors of this document are students I taught on the 1-week History and Philosophy of Evidence-Based Healthcare module at the Nuffield Department of Primary Care Health Sciences at the University of Oxford. The students are: Constantine, Shadia; Bailey, Roger; Darlow, Christopher; Dillon, Ryan; Eustace, Scott; Macdonald, Helen; Okeke-Von Batten, Karl-Marx; Paez, Arsenio; Peterside, Jason; Sisak, Ferenc)
Many students (medical and other) enjoy studying the History and Philosophy of Evidence-Based Healthcare (HPEBHC). However, it is an open question whether this actually improves or enhances EBHC. Here we report negative and positive answers to this question, as described by students on the most recent History and Philosophy of Evidence-Based Healthcare course. Where possible, we have provided evidence to support our reasons. In general, we conclude that overall, HPEBHC can improve the actual practice of EBHC.
Has studying the History of EBHC (HEBHC) Helped EBHC?
Those who cannot remember the past are condemned to repeat it — George Santayana
The Santayana quote seems to assume that everything that happened in the past (in this case the ‘pre-EBHC era’) was terrible, which is not true and it suggests a potential benefit to knowing the history of EBHC: we can prevent pre-EBHC mistakes.
Perhaps the main advantage of studying the History of EBHC (HEBHC) is that we can see how EBHC arose, giving students stronger tools to understand it. For example we learn from the James Lind and the scurvy tests how using empirical research methodologies saved lives compared with belief-based theories such as the theory of the four humours. Other historical examples teaching this lesson include the overturning of Dr. Spock’s advice to lay babies face down to sleep, and the use of steroids in premature children. Another point in favour of studying HEBHC is that it is may be required. The future builds on the past, and general medical knowledge is cumulative so it is not really possible to separate the past from the future. Indeed, looking at the past can inspire new revolutionary discoveries such as the development of synthetic quinine for the treatment and prevention of malaria. In addition to explaining, these historical events provide stories that are useful as memorable teaching tools.
At the same time, the benefits of studying history are not all positive. For one, there is currently limited evidence that studying broader humanities education (including the HPEBHC) helps medicine in general or EBHC in particular. Without evidence, some might say that studying history is mere navel gazing, and that there is little justification for diverting scarce resources to the study of HPEBHC. There may also be harms associated with a focus on the past. What if doctors learn the ‘wrong’ lessons from history? When James Lind described the treatment for scurvy, he was shouted down by powerful groups of clinicians. Seeing the power of ‘good old boys’ clubs’ in action may model poor or obstructive behaviour.
Moreover, studying the HEBHC can be frustrating because it becomes clear that many of the problems of history seem unsolvable, and have been ongoing for hundreds of years. For example, the same issue raised during the 1837 Paris debate about making individual decisions from average data is a concern that persists today. In response, there is evidence of progress, Sir Iain Chalmers and Murray Enkin set up the Cochrane Collaboration and Cochrane Reviews are now known to improve medical care.
In sum, studying the HEBHC can help understand and teach EBHC as well as provide inspiration for future EBHC leaders. However care must be taken to ensure that such teaching is evidence-based and a wise use of resources.
Has the Philosophy of Evidence-Based Healthcare (PEBHC) Helped EBHC?
The Philosophy of Evidence Based Healthcare (PEBHC) has made several contributions to evidence-based healthcare. First, studying the PEBHC allows participants to understand the rationale of the principles behind evidence and helps guide methodology in seeking it. This prevents students from accepting EBHC uncritically. Important issues such as the need for randomization, the need for blinding (masking) in study design, respecting participant autonomy and integration of participant values, have all been informed by the PEBHC. Second, by studying PEBHC, critical thinking skills required for critical appraisal within EBHC are developed. This allows to evaluate different ideological perspectives on the interpretation of evidence and to develop argumentative skills to combat non-evidence-informed lines of thought, that may otherwise divert action in a wasteful direction. Third, the PEBHC is arguably required to address the thorny issue of how to integrate values and ethics within EBHC. Fourth, the PEBHC can also be useful in situations in which expertise, patient values and research conflict with each other. For example, dental surgeons know that porcine bone graft have been shown to be better, however, using this material conflicts with the values of patients that practice Islam. No amount of time spent looking at the evidence will help with this, whereas philosophical consideration of values and ethics may play an important adjunct role.
Moreover the PEBHC includes ethics which is helpful to allow events such as the Tuskegee experiments, where the desire for evidence actually harmed people. Another example of this is the abuse of evidence of the Tobacco industry, when they hid research on the harms of tobacco use. Finally, PEBHC provides a forum for considering ‘alternatives’ to EBHC such as the EBM+ (plus) is movement who argue that mechanistic (e.g. animal) research should be or equal in the hierarchy than randomized trials.
In contrast with the benefits, there are several ways we can think off in which studying PEBHC may by unhelpful. For one, the constant scrutiny and skepticism encouraged by critical thinking is a double-edged sword. Continuous critique can lead to inaction in contexts where certainty is expected by patients. For example, the Japanese culture is very risk adverse and patients request and expect certainty from their physicians. Paying too much attention to critical appraisal of minor points might get in the way of patient satisfaction in these cases.
Another objection is that the practice of PEBHC can be time-consuming. Many might say that there is no time for ‘indulgent thinking,’ when the clinician is expected to just get on with the job of taking care of patients. One can spend a great deal of time pondering philosophical issues with little or no benefit or applicability to practice. Finally, philosophy is arguably subjective, so its conclusions can be equally subjective. This can have an impact on evidence-based practice because depending on one’s philosophical perspective, it is possible to impinge upon individuals’ autonomy and justice. This might support the practice of forced medical procedures ‘for the greater good,’ despite individual autonomy.
Before concluding there are two important points to make. First, one might consider history and philosophy as a joint discipline. We implied that the combined approach has a positive effect of EBHC. And it is important to note that a general problem with both HPEBHC as well as EBHC is that much of the information comes from developed countries and different conclusions might be drawn there. More research is required to expand this kind of work to see whether and how these issues play out in low and middle-income countries.
There are many good reasons to believe that studying the HPEBHC is useful for EBHC. These include teaching and learning aids, avoiding past mistakes, and teaching critical thinking. There are also some limitations, most notably that mere ‘navel gazing’ must be avoided: we need more evidence investigating the link between studying HPEBHC and the practice of EBHC. Such evidence could take the form of surveys (asking doctors who have studied HPEBHC how this has influenced their practice) as well as trials investigating the study of HPEBHC as an intervention. One thing is certain, those who study the HPEBHC will enjoy it in the meantime!