Evidence-based medicine: conceptualization unto application.

Some time ago a question was posed: How much of what doctors do is supported by good evidence? The answer of the US Office of Technology Assessment was that not many of medical treatments were based on good evidence.”1 However, universally, doctors are hardly challenged or checked on what they do to their patients. Medicine has always been a conservative profession and doctors have enjoyed protection. Many doctors, even though qualified, tend to practice and think of medicine as more of an art than a science. This has led to the practice of ‘empirical medicine’ in places where doctors do not update themselves.

Recently, things have changed. In 1992 the phrase “Evidence-Based Medicine” came into being. Ever since, the concept and phrase has dominated medical literature. Evidence-based medicine (EBM) has been described as “one of the most interesting and important developments in medicine in the past ten years.”2 However, I would like to state for history, that EBM is no new discovery. It is even older than the 18th century's French notions on the concept. Indeed, the origins of the concept can be dated back to the 9th century when the famous Muslim physician Arrazi (Razes 865-915) made a clear statement embracing the concept of evidence-based medicine: “What has become physicians’ consensus, based on analogy and supported by research experiments, should be your guide”3 Many Muslim physicians who followed Razes made even more elaborate and explicit statements on the concept of EBM.

For the sake of readers who may not be very familiar with the concept of evidence-based medicine, we provide here the original definition of EBM by David Sackett, one of the pioneers and initiators of today's EBM. According to him, EBM is the “conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” He further adds that: “The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”4

The concept and practice of EBM is increasingly becoming established in many reputable health institutions all over the world. Hundreds of papers, articles and editorials continue to be published about it. Specialized journals, such as the journals Evidence-Based Medicine and Evidence-Based Health Care, quickly achieved escalating subscriptions and local editions were published in French, German and Italian. Many other ‘evidence-based’ journals were announced, ranging from Evidence-Based Cardiovascular Medicine to Evidence-Based Nursing.2

Although the EBM concept has been well received by many, it has been subjected to criticism and mocking in articles and letters published in major medical journals.5–8 Some have claimed that EBM is an invention of insurance companies to cut expenditure on medicine. Others have thought it to be a “movement of managers and public health doctors rather than clinicians.”2 Defenders believe that most developments in EBM have come from clinicians seeing patients on a regular basis. To practice EBM, the practitioner is required to define his need for information into answerable questions. He is then required to track down the best evidence with which to answer these questions, critically appraise the evidence for its validity, apply the results of this appraisal in his clinical practices and evaluate his performance. Some barriers to using EBM have been encountered. These include the absence of good evidence, or that doctors cannot find it. Few doctors have been trained to assess quality of evidence and many of them are not competent in the use of computers. Sometimes cultural barriers pose a problem.

Nevertheless, EBM has so far been proved not to be ‘just a passing fashion,’ but a concept here to stay. Indeed, many believe that it will lead to a fundamental shift in the practice of medicine, with improvement in patient care and effectiveness of health care systems.2 Evidence-based medicine has now been adopted by many countries. In the UK the government thought EBM would ‘rationalize health care’ and a US Agency has set forth EBM as a priority and established EB practice centers. The French government has produced guidelines which have the power of law to support them.2 One author wisely remarked that ”rather than depicting EBM as a ‘revolutionary change’ in medical practice, it may perhaps be better described as the re-enforcement of an active and open-minded approach to new information, which some of us are already practicising.9

Evidence-Based Medicine in Saudi Arabia

Interest in EBM in Saudi Arabia in recent years has been manifested in a number of activities. Workshops and courses on EBM have been held in King Saud, King Abdulaziz, and King Faisal universities in Riyadh, Jeddah and Dammam, respectively. The objectives of these workshops and courses were to introduce their participants to the concept of EBM and to help them acquire and advance their skills in the practice of EBM. These workshops attracted many faculty and non-faculty doctors. International speakers were enlisted to introduce and sell the concept at the beginning. However, there is now a considerable number of indigenous faculty and physicians who are quite learned and versed in the concept. Activities and functions related to EBM have been pioneered and lead by the departments of family and community medicine in the three universities, perhaps because EBM has been “hailed as the future educational paradigm for family medicine.”

Several articles by authors practicing in Saudi Arabia have appeared in the local medical journals.91011 Some of them were high-powered well-written reviews. In his excellent article on EBM published in the Annals of Saudi Medicine, Alan Stewart convincingly argued that “emerging health care systems, such as those in the Middle East, have the opportunity to gain from the experience of those in developed countries which now face crises in resource management.” He added that “EBM has the potential to steer such systems away from cost-ineffective practices and to equitable distributions of healthcare funding among primary, secondary and tertiary care”.10 He believes that the educational and management tools exist, and resources, though finite, are sufficient to implement evidence-based medicine. He has called for embracing the EBM philosophy now, as the pivotal step towards provision of ‘best care’ in the new millennium.

In a study on primary health care physicians in Riyadh, respondents welcomed EBM, although they had low level of awareness about it. About 13% had access to bibliographic data bases and only 10% to the worldwide web.12

A national evidence-based medicine advisory board has been established to promote implementation of EBM in Saudi Arabia. The board met several times and theoretical frameworks were put together with a proposal of activities at central and peripheral levels. These include the establishment of a reference e-library, local website, training, the holding of workshops and courses on EBM. These are all indicators that decision makers and university teachers are heading towards establishing EBM in clinical and other practices in Saudi Arabia. This would make Saudi Arabia a leading country in the region to adopt and implement EBM. However, for this trend to continue, a number of measures must be considered.

First, medical schools in Saudi Arabia need to respond by considering the adoption of EBM curriculums. Faculty need to be versed not only in EBM but also in best-evidence medical education (BEME). An important source of references on the latter is the BEME Collaboration Website.

Second, the policy of the Ministry of Health in publishing protocols and guidelines for the management of the more common problems encountered in clinical practice should be encouraged. Already existing protocols need to be revised and updated accordingly to the best available evidence.

Third, the world wealth of literature and other resources on EBM needs to be fully utilized. This should be made available to practicing physicians on all levels of health care. A selected list of websites on EBM is given in Table 1.

Table 1

Evidence-based medicine – selected websites

Fourth, for EBM to be successfully implemented, there is need for legal, political, and financial support to set the structure.

Finally, and as a contribution from the Saudi Society of Family and Community Medicine to the establishment of EB clinical practice, a new section in this journal will soon be allocated to EBM to furnish our readers with the latest in the field.