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The promise and perils of evidence-based medicine. (Part 1: Health Care Trends).


* Evidence-Based Medicine (EBM)

* Clinical Practice Guidelines

* Better Outcomes

* Cost-Effective Health Care

* Gathering Reliable Clinical Evidence

* Clinical Decision-Making in the Information Age

Numerous studies have demonstrated that there are wide variations in the way physicians manage similar patients. This suggests that an evidence-based approach could lead to better outcomes with less cost. But practicing evidence-based medicine requires new skills, such as using computerized databases and applying the rules of evidence to primary and integrative studies in the medical literature. The progress of evidence-based medicine will depend in large measure on how quickly these new skills can be developed and integrated into the practice environment. Here's how six experts see the promise and the perils of evidence-based medicine, now and in the new millennium. Part 2 of the panel discussion will explore the new provider team, which includes nurses and, more recently, pharmacists, who are collaborating with physicians to provide disease management and drugs therapy management services.

IN A 1997 ARTICLE IN Molecular Diagnosis, Gordon H. Guyatt, MD, FRCPC, professor in the departments of Medicine and Clinical Epidemiology and Biostatistics and Medicine at McMaster University in Hamilton, Ontario, where evidence-based medicine (EBM) originated, defines EBM as the conscientious and judicious use of current best evidence from clinical care research in making health care decisions."

On its face, this doesn't sound like much of a threat to the status quo, but it could take a lot of sugar to make EBM go down with practicing physicians. To implement evidence-based clinical care efficiently, practitioners may have to develop new skills, such as using computerized databases and applying the rules of evidence to primary and integrative studies.

Arriving at clinical decisions in an evidence-based practice might Include the following:

* precisely define a patient problem and what information is required to solve it;

* conduct an efficient search of the literature;

* select the best of the relevant studies;

* extract the clinical message;

* apply it to the patient problem; and

* present the clinical message to colleagues.

The implications of EBM for clinical practice, demand management, guideline development, research, medical education, informatics, and health policy are profound. At least in theory, EBM holds out the promise of better outcomes and more cost-effective health care, simply by making the results of existing clinical research available to clinicians.

Three main factors account for EBM'S worldwide appeal. First, EBM posits a hierarchy of evidence, with randomized, controlled, double-blinded studies at the top and observational studies at the bottom in terms of their predictive value. Second, variations in the way physicians manage similar patients suggest that an evidence-based approach could lead to better outcomes with less cost. The third reason for the interest in EBM is that fewer resources will be available for health care delivery in the future.

Guyatt currently heads the Evidence-Based Medicine Working Group, which consists of 18 clinicians and researchers in Canada and Great Britain. He emphasizes that history-taking, physical examination, clinical experience, and an understanding of physiology and disease mechanisms remain fundamental to good clinical decision-making and patient management. What separates evidence-based clinicians from traditional practitioners is an unwillingness to accept practice guidelines unsupported by reliable clinical evidence.

A formidable challenge for evidence-based clinicians is the sheer volume of data already available. The Cochrane Collaboration is a worldwide multidisciplinary network whose goal is to provide systematic reviews of approximately 250,000 randomized trials of health care interventions and present these reviews in a way that's usable by both clinicians and patients.

Evidence-based decision-making will still involve trade-offs, preferences, and value judgments. At a time when more and more health care consumers have access to and use clinical information themselves, evidence-based practitioners will also be able to help their patients evaluate that Information and share decision-making with them.

All of which is a tall order for a profession that already has a full plate. Factor in considerations like malpractice liability as this new evidence impinges on the community "standard of care, and it could be a while before EBM makes a difference.

The Physician Executive: What are some of the basic elements of evidence-based medicine?

Eisenberg: The basic tenet of evidence-based medicine (EBM) is to take the science of clinical practice and translate it into the delivery of care to patients.

McGinn: EBM connects the research with the practice. Its a translational process for clinicians.

LeTourneau: Are we just talking about practice guidelines based on research?

McGinn: No.

Eisenberg: The mechanism by which the evidence gets translated into improved practice through a clinician could be guidelines, education, or electronic reminders. But the key is that practice is based upon scientifically demonstrated connections between cause and effect, that if I do a diagnostic test or a therapeutic intervention, then a scientifically valid analysis has shown that this test or intervention will likely result in a particular outcome.

The Physician Executive:

Can you cite some examples of what is considered gospel in traditional practice but, in fact, has been shown to be not very well supported by the evidence?

Reinhardt: Well, there is the old example of gastric freezing.

Eisenberg: Yes, that's one of the famous ones. They used to freeze the stomach to take care of ulcers. It was an operation that was developed at the University of Minnesota, where I guess they had a lot of ice and couldn't figure out what to do with it.

Nishikawa: There was a time when vascular and neurosurgeons did internal carotid to external carotid bypass surgery to alleviate symptoms that were due to brain ischemia. That was proven in a randomized trial to be no more effective than medical therapy. An even more extreme example would be the use of certain anti-arrhythmic agents for treating ventricular arrhythmias or frequent PVCs in people that have recovered from a myocardial infarction. The CAST (Cardiac Arrhythmia Suppression Trial) trial showed that three antiarrhythmics decreased the arrhythmias but also caused earlier death in the people taking them, so we don't do that routinely after an MI anymore.

LeTourneau: I have a very simple example. We've thought for years and years that ear infections have to be treated with antibiotics, but recent research has shown that 50 to 75 percent of ear infections are actually sterile, and the antibiotics probably aren't helping at all and may even be contributing to microbial resistance. EBM and the Agency for Health Care Policy and Research

The Physician Executive: What is the Agency for Health Care Policy and Research's (AHCPR) interest in EBM?

Eisenberg: AHCPR was established in 1989 to generate and then translate information about medical care to improve the quality of care. So the AHCPR really rests on a foundation of evidence-based medicine, although we weren't calling it that in 1989. We were thinking of it more as outcomes and effectiveness research, but the principles are the same. AHCPR is the lead federal agency that's responsible for funding and conducting research to develop new methods and tools to use evidencebased principles and then translate those findings into improved practice that will result in better outcomes and better quality of care.

The Physician Executive: How do the Evidence-Based Practice Centers figure into the agency's work?

Eisenberg: They're all in North America, with 11 of the 12 in the United States. These centers competed successfully in a call for proposals to institutions that would serve as a national public resource to analyze the evidence for diagnostic and therapeutic services. We put out a call for topics once or twice a year. We're about to assign 12 to 20 more topics to these centers and they will do very careful analyses to address specific questions, such as whether new antidepressants work as well as older ones or better. Or what's the best way of taking care of urinary complications in people who are paralyzed. Our partners in these centers not only identify important topics but also generate the evidence reports. The agency doesn't write guidelines anymore. What we do is partner with people who translate the evidence our contractors generate into guidelines or an educational program or some other mechanism to use the evidence to improve quality.

Reinhardt: As one of the health services researchers who got AHCPR founded, I think you should explain why the agency doesn't do guidelines anymore.

Eisenberg: Two reasons. One of them is because it was a political third rail. When AHCPR was doing guidelines, the general sense was that this was a risky business for a federal agency to get involved in. But even more fundamental is that I really believe we ought to be a science partner to people who are making decisions about health care. There isn't just one path to heaven. There are different ways of taking care of different patients, but all of them ought to be based upon good evidence. So our sense is that we ought to be generating the science and that our partners ought to be generating the pathways.

The Physician Executive: When did these Evidence-Based Practice Centers get underway and are you already generating results?

Eisenberg: They started in the beginning of 1998. It was really important to have a quick turnaround. The Evidence-Based Practice Centers have been terrific in putting out really polished reports within several months. They're as good as any reports using scientific methods to analyze existing data as I've seen. But it's existing data. They don't gather new information. We also sponsor investigators to generate new research that ultimately might find its way into an evidence report. At the other end of the pipeline, we have a new National Guideline Clearinghouse website (, where we're making evidence-based guidelines available. We don't censor them, we don't edit them, we just report them. We put them on the website with abstracts acceptable to the groups that wrote the guidelines and allow you to do side-by-side comparisons of the methodology and the results of these guidelines.

The frustrating thing for us actually is that the number of topics that people are interested in getting better evidence for is between five and ten times the number of topics that we've been able to fund on each cycle. My guess is that as more people know about this, we're going to get even more nominations, and the gap between what we can do and what we might do is going to increase.

The Physician Executive: What's the price tag on this effort?

Eisenberg: The Evidence-Based Practice Reports program I just described is a $3 million a year project. The National Guideline Clearinghouse is a $6.5 million project over four years. And then we fund a lot of investigator-initiated outcomes and quality research, and that's several million dollars more per year.

EBM and health care costs

The Physician Executive: What are the implications of EBM for medical education, more cost-effective health care, and better outcomes? Can we expect lower costs?

Eisenberg: Well, potentially.

Reinhardt: Lower cost per unit of outcome, yes. In fact, when we initially lobbied Congress to get this agency started, we always pointed out that on some therapies it would lower spending per year, while in others it might increase spending. But basically we expect to lower costs per unit of some outcomes. It could be quality-adjusted-life-years (QALYs) or pain-free days, whichever way you measure outcome. It doesn't mean spending will go down, because if something is very cost-effective, you may consume more of it.

The health policy debate always confuses cost with spending. The word cost implies dollars per unit for something, like cost per patient visit or cost per bypass operation. The word spending refers to dollar flows per unit of time, like health spending in 1998. Technical progress may lower the cost of a procedure but raise total annual spending on the procedure precisely because the cost per unit is down.

McGinn: I think this is a very important discussion, that EBM will drive costs if it's applied. A lot of people think EBM is cheaper, but evidence is just evidence. If the evidence shows carotid endarterectomies are the way to go, that evidence doesn't come with a price tag. The difficulty comes when, for example, pharmaceutical companies or other companies become very sophisticated in this area, and then manipulate the evidence to their advantage.

I'm mostly involved with residence education, and drug reps, for example, are becoming more sophisticated about EBM, in some ways more sophisticated than many of the residents, so they can emphasize things very selectively. And from a managed care perspective, you can choose evidence for things that are cost-effective or cheaper and maybe not focus on things that are more expensive.

How to get clinicians to think and practice EBM

The Physician Executive: How difficult is it to get clinicians to think and practice in EBM terms?

Eisenberg: The key here is that evidence is necessary but not sufficient to improve practice. It's important to have a scientific foundation for practice, but there are so many other influences on physicians' practices that evidence can be overwhelmed by those other influences, such as financial incentives, organizational disarray, lack of information about what the patient's situation is, or poor leadership. Evidence is a very important one, but it's only one of a multitude of influences.

LeTourneau: I agree. A big barrier I run into is that you can prove to a physician that only one out of 10,000 patients gets a specific complication. but by golly, if physicians have had one in their career, they feel like they must guard against it. And if there's been a malpractice suit around that, the risk is even higher that they're going to ignore the evidence-based medicine. This is a barrier because, as physicians. we're taught that we are personally responsible for our patients and we have to do what we think is right based on our experience, not necessarily what the evidence shows.

The Physician Executive: What is the Evidence-Based Working Group doing these days?

Nishikawa: The Group is broadening its scope, looking not just at things like clinical trials or diagnostic tests, but also how to measure quality of life appropriately. So we're looking at qualitative in addition to quantitative research, and how to appraise that kind of literature. We're also looking at other steps in the clinical process. like the generation of differential diagnoses, generation of the character of the disorder or disease, and how to read through papers that deal with that at the front end before you get to the actual diagnostic tests.

EBM as a tool to deal with information overload

The Physician Executive: I read somewhere that something like 200.000 studies are potential candidates for evaluation by evidence-based methods. There's a tremendous amount of existing data Out there, isn't there?

Nishikawa: Well, a lot of evidence-based medicine is finding the information that's relevant to the individual patient or group of patients that you're taking care of.

McGinn: What EBM does is try to give the clinician the tools to use it. It tries to make clinicians good consumers of the literature so they can interpret that literature as it relates directly to the care of an individual patient. Otherwise they may just become overwhelmed with all that information.

Eisenberg: What we've seen in the evidence reports is that in answering a question. they will often start out with a very large number of articles, and then set criteria for the standards that the articles have to meet to be considered evidence-based. In most of these analyses, they start with several hundred articles that they've found through a Medline search, and end up with less than a hundred that meet the criteria.

EBM and managed care

The Physician Executive: How compatible is EBM with the managed care environment in the U.S.?

LeTourneau: In Minnesota it's very compatible. One of the things that we try to work on in health plans and in the delivery system is helping physicians learn how to be more data-driven. Minnesota is largely not-for-profit, and I'm not sure whether that makes a difference, but if we can demonstrate better outcomes, then the evidence is what we expect to drive decision-making.

Eisenberg: But one of the concerns about managed care is that evidence-based medicine can cut both ways. On the one hand, we'd like to be sure that there's good evidence for the things that we're doing, but if you were mean-spirited, you could make a case for denying services for anything that didn't have a good evidence base. If you use randomized controlled trials as the standard, you wouldn't give penicillin to anybody with pneumonia, and you wouldn't do most surgical procedures. One of the risks is that we not equate an absence of data with an absence of effectiveness.

LeTourneau: I think that's a very good point. My assumption is that we only use evidence-based medicine when there actually is evidence. If there's no good evidence or if there's conflicting evidence, you go with the general standard of care. That's been the methodology we've used in Minnesota.

Reinhardt: I would say that EBM is the sine qua non of managed care, the whole foundation of it. Because what are you going to manage if you don't have some norm of management? When people produce cars, they have normative ideas of how a car should be put together and how much it should cost. That applies to health care production as well.

LeTourneau: I think you're right. You need the evidence to manage care. At the same time, I think any good thing can be twisted and used for the wrong reason. When we talk about managed care saying, "well, there's no evidence, therefore we're not going to do what is accepted by the community," that's a possible example of using evidence-based medicine in the wrong way.

Reinhardt: I can't imagine how long an HMO that would do that would stay in the market.

McGinn: That's what I would call selective evidence-based medicine. If you only look at the evidence in areas that may reduce costs, you may not really bring to light other areas where it costs you more money. There's so much evidence and as a managed care organization, you're always picking and choosing where you're going to focus your energies. So what you select is important.


The biggest conflict in managed care that I would see with EBM is how much evidence do you need, and what is the standard? If you have an extremely rare disease and some radical procedure has been tried ten times in the history of the world and it worked three of those times, is that enough evidence?

EBM research is an example of a "public good"

The Physician Executive: Are we seeing employers and Insurance companies buying into EBM?

LeTourneau: Yes. I think insurance companies and health plans and employers are looking for evidence-based medicine.

The Physician Executive: Are they spending any money on developing their own evidence-based guidelines?

Eisenberg: Some are, but most of the plans don't have enough of a research base to sponsor or conduct this kind of work. A few do. Kaiser Permanente, some of the Minneapolis plans, Group Health of Puget Sound, Harvard Pilgrim Health Plan have spent some money on generating evidence, but I think most of them are focusing on using the syntheses and the reports that have been done. They're also focusing on what somebody here said, which is concentrating not so much on generating the evidence as on generating clinicians who are able to use the evidence.

Reinhardt: It makes sense to me that non-profits do more of this kind of research than for-profits. The reason is that the kind of information coming out of such research is really a public good. A public good has the characteristic that when I consume it, you don't have any less of it and can consume the same amount. And that characteristic implies that the private market will always underestimate the social value of the product from research. But because such knowledge is highly valuable from a social point of view, someone should finance it. and that is usually government. That is why we have the NIH. NASA, the National Science Foundation. and the AHCPR.

Eisenberg: One of the nice things I've seen from the perspective of AHCPR has been the uniform bipartisan support that exists for what Uwe's describing. People who are left of center feel that it's critical in order to have equity and access to care, and people right of center feel that it's critical in order to have a market that works. No matter what your political bent, you can make a very good case that funding the generation of better evidence ought to be a government responsibility.

The Physician Executive: What's the single biggest misconception about EBM?

Nishikawa: The biggest one I find is that a clinical experience is worth nothing in an evidence-based medicine environment. That's a misconception because evidence is added into the mix of clinical experience and patient preferences to try and come up with the best decisions for the individual.

LeTourneau: Another misconception is thinking that if you build it they will come. Just because you say something is evidence-based and can prove it does not necessarily mean that anybody will use it. It's all in the execution and how you do your implementation, not all in how you present your evidence.

EBM is a worldwide phenomenon

The Physician Executive: EBM is a worldwide phenomenon. Is anyone making significantly more progress than most?

Eisenberg: In April. the British opened a new agency called the National Institute for Clinical Excellence, which has a great acronym, NICE. What this reflects is a worldwide movement because the French already have an organization called ANAES, which is the Agency for Accreditation and Evaluation of Scientific Evidence. The World Health Organization has just created a unit called Evidence for Public Health. It has recruited people like Julio Frenk, Chris Murray, Allen Lopez, Dean Jamison, David Evans, and Tessa Tan Torres, a world-class group of people, to work for the WHO because Gro Brundtland, the Director General, believes that an evidence-based approach to public health is as important as an evidence-based approach to clinical medicine.

The Physician Executive: Is there any danger of redundancy?

Eisenberg: Well, the challenge is so huge right now and the resources are so relatively small that we're not going to stumble across each other. But the various government agencies have been communicating with each other, and there also are international voluntary associations like the Cochrane Collaboration and the International Clinical Epidemiology Network that are encouraging collaboration across nations.

Reinhardt: When it comes to evidence-based medicine, do we Americans recognize the very valuable contributions made abroad any more than we recognize the valuable managed care techniques that have been used abroad for many years and that we are reinventing only now? For example. hospitalists, home care, or physician practice profiles, to mention just a few?

Eisenberg: I think we probably recognize that most of the leadership in evidence-based medicine came from Canada and England, not from this country.

Obstacles to EBM

The Physician Executive: What's the biggest obstacle in getting physicians or clinicians to think and practice in EBM terms? (editor's note: Mark Wilson now joins the discussion.)

Wilson: I think there are several. One is simply getting people over the vocabulary, which sometimes can be daunting. Second, a lot of clinicians have a tendency to enjoy numbers less, and so working with likelihood ratios, or numbers needed to treat, or absolute risk reduction sometimes seems a bit intimidating. That sometimes requires convincing people that they don't have to be statisticians to practice in an evidence-based fashion.

Another practical Issue is just simply being able to translate their information needs into specific questions so they can seek out the best available evidence and recognize that the best available evidence sometimes is not going to be the ideal evidence. If it's not a randomized controlled trial, some residents throw their hands up and say, 'Obviously I can't practice EBM.' We still have to take care of patients, hopefully with the best information, but maybe with less dogmatism if the quality of the evidence is not as strong.

McGinn: There's also a fear of the computer. Many physicians feel the information superhighway has passed them by, and EBM is definitely connected with that. Getting physicians over that fear and getting them to harness all this information is a big step. In most of the workshops that we're involved in, a big component is getting people to sit down at the computer and just get over that fear and learn to really use it.

Eisenberg: Two other issues are important, and they both have to do with physicians feeling as If they're losing power or autonomy. One is the sense that evidence-based medicine is cookbook medicine, that one answer pops out of the statistical analysis and therefore you don't use a lot of judgment. I think all of us would argue that exactly the opposite is the case--that it allows you to individualize the care based on what the patient's preference is and what the likely outcomes are.

The second point is that many people advocate the use of evidence to inform patients, to make them more empowered consumers of health care, and I think a number of physicians find that frightening. What we'd like to argue is that this is a partnership with shared decision-making, and that the more the patient understands what the likely outcomes are, the more the physician can write a prescription for information rather than a prescription for a drug, and the more the doctor can work with the patient as a tutor and a partner. But many physicians are much more comfortable in the role of just telling the patient what to do and when to do it.

The Physician Executive: Is there a generational aspect to what you're describing?

McGinn: I think it's somewhat generational. We are constantly challenged by our medical students and residents as they come through the ranks with more computer skills and the ability to harness all this information. I'm constantly being pushed because these students are on the Internet at the age of five and then work their way up. And then there are some department chairmen who are really struggling to send email.

EBM in 2010

The Physician Executive: Where will EBM be in another 5 or ten years, and what will it have accomplished?

McGinn: This generational issue will eventually lessen and information technology is just going to marry with the evidence. I think EBM will help us figure out how to do that. Guidelines on the Internet, immediately accessible from every computer in every clinic.

More and more, the evidence will be sitting right in front of us as we practice medicine. The latest thing is the Palm Pilot with online access to these guidelines so that you're walking down the hall and you're writing a prescription on your Palm Pilot and looking at the guideline all at the same time. The impact of information and our ability to use it is going to be dramatic.

LeTourneau: In ten years we'll have the physicians who are 45 to 55 now who rely on their extensive experience but still read the studies, and then we'll have the younger physicians who have been trained to embrace the evidence that's available to them and actively use it in decision-making. I think it's going to be very difficult to get the 45 to 55 year-old group to rely heavily on evidence that doesn't support their experience. There will be some, hut I think many won't go that way.

Eisenberg: In five or ten years it won't just be physicians in Missouri saying, 'Show me.' There will, of course, be outliers, but increasingly it'll be a 'show me' profession where doctors ask for the evidence before they take action.

What might also happen is that the rest of society is going to join the clinicians and ask for the same kind of evidence. Patients will start to ask their physicians what the evidence is for the prescription or for the diagnostic test.

The last bastion will he the law. One issue we're going to have to work out is that the law defines evidence in a very different way than we've been describing today. It describes it by what a so-called expert says or what a judge decides to admit into the courtroom. And unless we can get some appropriate conversation between the evidence-based medicine and the evidentiary law people., then we may run into a very serious barrier in using evidence-based medicine in practice.

Reinhardt: I have a hope and a worry. The hope is that, in fact, in five to ten years medicine will rest on a far firmer empirical basis, which really has been lacking in the past. The worry is what if there will be a huge plethora of guidelines, the way you have conflicting formularies that drive doctors nuts? People just may drown in information, and in the end say, "A plague on all your houses." Or you might have experts duke it out before judges and juries.

If you look at economics as a profession, for almost any theory, you can buy in the market a counter-theory. My fear is that medicine will slide into the same intellectual morass in which economists now wallow, often with politics practiced in the guise of science. In medicine, it might be profit-maximizing in the guise of science. I look to John to make sure that this whole evidence-based enterprise doesn't become cumbersome, ethically compromised, and ultimately useless.

The Physician Executive: In Canada, there is no such thing as for-profit medicine. Does that mean Uwe's worries are less likely to become I reality in Canada?

Nishikawa: Yes, I think so. Generating the science as well as generating ways of implementing it are a lot more uniform, I suspect, in Canada. Where I live, the government of Ontario funds some research through the Ministry of Health. It also funds health care, so there is potentially a smoother continuum between the generation of information and its use by hospitals or clinicians.

Wilson: I may have rose-colored glasses on, but I look not so much towards evidence-based medicine as dictating care, but that clinicians will become more comfortable with the approach that's involved in evidence-based practice, that It can be an empowering way to approach clinical practice. The evidence alone doesn't make decisions. Even If you've got really strong evidence and well-grounded practice guidelines for given scenarios, it still may not be right for the specific patient that's in front of you. Individual clinicians and their patients engaging in shared decision-making is the direction I see this moving in the next five to ten years.

Three other quick things. I'm hopeful that we'll continue to have increasing amounts of clinically relevant research. Second, clinicians will be increasingly comfortable with seeking out patient-specific literature for individual problem-solving. And finally, this issue of applicability. When we have the evidence, in what sub-groups is it most beneficial, and what sub-groups may benefit not as much as what the overall results show us? How do we understand this process of generalization or individualization when it's just a specific patient sitting in your office this afternoon?

EBM may require multidisciplinary teams

The Physician Executive: How many physicians can afford to see two or three fewer patients during the day because they're sitting at the computer for that amount of time looking for evidence in the literature? Will it instead be the PA or nurse practitioner that will search and retrieve relevant evidence?

McGinn: This is a very important question. How do busy clinicians outside the world of academia and training centers change what they do? Where do busy doctors get their information now? They hang out at the chart rack and ask a colleague. We have to look at role models and what systems can be put in place to remind physicians to behave in an evidence-based fashion.

Eisenberg: One possibility is that physicians will be able to work in teams and that the evidence can be shared so that members of the team can contribute in a way that's consistent with their background. That might mean mid-level practitioners would be more active as part of a team. With the right kind of physician executive leadership, a team with multiple disciplines can practice together effectively using good evidence.

But there are also librarians and epidemiologists who have not generally been considered practitioners or members of the clinical care team. If we're really serious about evidence-based medicine, then you'd have to envision a care team in a group practice as including a good librarian and somebody who's got some strong epidemiologic skills, as well as nurse practitioners and physician assistants. If we're thinking about an information age, then it's skill in using information and generating conclusions and knowledge from that information that's going to be valued increasingly. So it may be that midlevel practitioners will assume some of these new roles.

LeTourneau: When I think about an information system fix for this, I think of an electronic medical record that has automatic pop-up screens so that when you enter a diagnosis, a screen pops up that says, 'The evidence suggests this.' Then there's a group of people who decide what goes on the pop-up screens and that's where you might have your librarian and your analyst and some kind of team with clinicians.

McGinn: One of the areas we often don't think about when we're talking about evidence-based medicine is diagnostic workups. To me, what's the right test to order is where I think physicians fall short. This mostly treatment-based concept of EBM tends to leave out the diagnostic work-up, which is very expensive and usually not based on evidence because we don't have a lot of evidence to show what's the correct work-up. So before the diagnosis is even put into the electronic medical record, how did it get there? How many CT. scans did they order?

Reinhardt: One has to congratulate the American medical profession for grappling with this issue of evidence-based medicine. I don't know of any other profession that's actually even begun to think about re-examining their professional work in this way. I've never heard of evidence-based pedagogy, for example, and you haven't heard it about the way law is practiced.

McGinn: The ultimate question, which I know some of us who are very involved with education get constantly asked, is what's the evidence to support the evidence-based approach? That's something we'll be doing. looking at outcomes and seeing that we're showing improvements.


The author would like to thank Dr. Bill Cordell for his suggestions and for his invaluable help in identifying health care innovators.


The following list of websites, journals, and articles is intended to provide physician executives with additional resources on evidence-based medicine.


Centre for Evidence-Based Medicine (UK):

Evidence-Based Care home page: Guideline Clearinghouse:


ACP Journal Club is published bimonthly by the American College of Physicians-American Society of Internal Medicine. A subscription is a benefit of membership in ACP-ASIM and subscription rates may be obtained by calling 800/523-1546, ext. 2600.

Clinical Evidence will be published twice a year by BMJ Publishing Group (June and December) and is available for $99. Call 800/2-FON-BMJ to order.

Evidence-Based Health Policy & Management is published quarterly by Churchill Livingstone of Edinburgh, London, New York, Philadelphia, San Francisco, Sydney, and Toronto, Subscriptions are available for $99.

Please call 44-0-181-300-3322-1999 to subscribe.

Evidence-Based Medicine is published bimonthly by the American College of Physicians-American Society of Internal Medicine and the BMJ Publishing Group. Call 800/523-1546 or email for subscription rates Medical Decision Making (MDM) is the official journal of the Society for Medical Decision Making. Subscriptions are available for $98 and can be ordered by calling 800/962-1892.


Evidence-Based Medicine Working Group. Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine. JAMA. 1992; 268: 2420-25.

Sackett, D.L,, et al. Evidence-Based Medicine: What it is and what it isn't [editorial] BMJ. 1996: 312: 71-2.

Haynes. R.B., Sackett, D.L., Gray, J.A.M., Cook, D.J., Guyatt, G.H. Transferring Evidence from Research into Practice: 1 The Role of Clinical Care Research in Clinical Decisions. ACPJ Club 1996; 125:A14-16.

Schulz, K.F,, Chalmers, I., Hayes, R.J., Altman, D.G. Empirical Evidence of Bias. Dimensions of Methodological Quality Associated with Estimates of Treatment Effects in Controlled Trials. JAMA 1995:273:408-12.

Hayward. R., Wilson, M.C., Tunis, S.R., Bass, E.B., Guyatt, G.H., and the Evidence-Based Medicine Working Group. Users' Guides to the Medical Literature VIII. How to Use Clinical Practice Guidelines. Part A. Are the Recommendations Valid? JAMA 1995:274:570-574.

Oxman, AD., Sackett, D.L., Cook, D.J. for the Evidence-Based Medicine Working Group. Users' Guides to the Medical Literature. 1. How to get Started. JAMA 1993:270:2093-2095.


The following experts participated in Part 1 of this panel discussion, conducted on March 22, 1999 via conference call:

John M. Eisenberg, MD, MBA, is Administrator of the Agency for Health Care Policy and Research (AHCPR) in the Department of Health and Human Services. Dr. Eisenberg previously held positions in academic and clinical medicine and is published widely in periodicals and books. He served as Chairman of the Congressional Physician Payment Review Commission and is a member of the Institute of Medicine of the National Academy of Sciences.

Barbara LeTourneau, MD, MBA, FACPE, is Vice President of Medical Affairs, North Region, of Allina Health System. Her responsibilities include leadership of the 700-physician staff of Mercy and Unity Hospitals in Minneapolis, Minnesota. Dr. LeTourneau is a practicing emergency room physician and past President of the American College of Physician Executives.

Thomas G. McGinn, MD, MPH, is Assistant Director of the Residency Program at the Albert Einstein College of Medicine/Montefiore Medical Center, where he is responsible for curriculum development and the training of 50 house staff physicians. He also chairs the evidence-based medicine faculty development program and edits the evidence-based medicine series in the Annals of Emergency Medicine. Dr. McGinn lectures and writes frequently about evidence-based medicine and clinical prediction rules.

Jim Nishikawa, MD, FRCPC, is Associate Professor of Medicine at McMaster University, Associate Member of the Department of Clinical Epidemiology and Biostatistics, and a member of the Evidence-Based Medicine Working Group. Dr. Nishikawa is Associate Editor of the ACP Journal Club/Evidence-Based Medicine. He has a special interest in medical education and is the Vice Chair of the Royal College oral examination board.

Uwe Reinhardt, PhD, is James Madison Professor of Political Economy and Professor of Economics and Public Affairs at Princeton University. He has received several honorary doctorate degrees and has served on a number of government committees and commissions. His current memberships include the Institute of Medicine of the National Academy of Sciences and the External Advisory Panel for Health Nutrition and Population of the World Bank. Dr. Reinhardt is widely published and serves on numerous editorial boards.

Mark C. Wilson, MD, MPH, is Program Director of the Internal Medicine Residency at Wake Forest University School of Medicine. He teaches evidence-based medicine nationally and internationally, with ongoing academic projects such as "Core Competencies for the Effective Practice of Evidence-Based Medicine" and "Implementation and Use of a Clinical Informatics Network." He is widely published on EBM and practice guidelines.

Bob Carlson thinks and writes about health care. He lives north of Indianapolis and can be reached by calling 317/769-4609 or via email at
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Author:Carlson, Robert P.
Publication:Physician Executive
Geographic Code:1USA
Date:May 1, 1999
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