…an objective experiment to determine its efficacy in [humans] was needed…But what sort of experiment? An English statistician named Bradford Hill…proposed an extraordinary solution. Hill began by recognizing that doctors, of all people, could not be entrusted to perform such an experiment without inherent biases…Hill’s proposed solution was to remove such biases by randomly assigning patients to treatment…versus a placebo. The Emperor of All Maladies, 131-132
Medical professionals have a special obligation to communicate without ambiguity, both in the written or spoken word; they depend on their communication skills to interact productively with other medical experts, their colleagues, clients and their families, and the public at large. The healthcare professional must often act as intermediary between the specialized world of scientific research and the more pragmatic world of the general public.
Evidence Based Medicine
There was a time when clinical health practitioners (HPs) didn’t have to worry as much about the kind of reading — even writing — they would have to do. Yes, HPs had to write case histories and read the practitioner literature to complete the requisite continuing education units to keep accreditation, but the degree to which HPs read — or felt they had to read — the research literature varied tremendously.
Now, there is a new model of HP literacy — Evidence-Based Medicine (EBM) — acting as the foundation of Evidence-Based Practice (EBP). Though there is some variation in what each term covers — EBM more strongly connotes the medical research literature while EBP implies the use of the literature as it intersects clinical activities — both require that the HP consult “evidence” when treating patients.
“Evidence + Experience = Expertise”
The best known definition of EBM comes from Sackett et al., 1996, p.71-72 — here’s the main gist:
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer.
In essense, EBM states a good HP uses all the information available to them to make decisions when evaluating and treating patients. This sounds pretty logical, doesn’t it? What kind of HP would not want to use the best combination of evidence (results from scientific study) and expertise (experience with actual patients)?
In practice, though, EBM/EBP is tough — as are most solutions to elegantly and simply stated problems. Challenges to implementing EBM include: 1) the aggregation of evidence into a form everyone can use; 2) the literacy skills required to use the aggregated evidence; 3) ways of making individual expertise available as consumable information; 4) working EBM strategies into an HPs work flow; and 5) systematic ways of taking patient preferences and values into account.
This is the culture of health/medicine that you are moving into. No medical field is immune to the pressures of EBM, and in 2009, the US government allocated considerable funds to solving the challenges mentioned above, especially the first one. To my knowledge, there is only one systematic way of making individual expertise available as information — through published case studies. Case studies are written reports of the medical experience of a single patient (or small group of patients with the same pathology). Sometimes the case study is of a typical patient. Other times, the case study follows the medical treatment of an atypical patient, whether the atypicality resulted from symptoms, diagnosis, treatment, relapse, etc. These case studies are more frequently published in journals.
Assessing patient preferences is not so well addressed in the health sciences, and is an area where both research and application could use dedicated practitioners (though trade journals aimed at clinical practice do help); instead, health practitioners rely on an apprenticeship system by placing new clinicians in internships, externships, rotations, residencies, etc., to learn such skills before they can be fully independent.
To begin your literacy journey into the world of EBM, you’ll need to understand the structure and goals of different types of medical articles and the type of evidence each provides. All good writing begins with reading, and once you learn how a particular sort of article is structured, you can quickly get a handle on how to assess that kind of work and the value it has for you as a practitioner. That won’t take as long as you think it! But even an hour spent understanding how published articles are organized will help you tremendously as a writer because you’ll be able to “see” the structure of the information in a new way. You’ll understand what a reader needs to find your work accessible, comprehensible, and credible.