Skittles the ferret. She has little to do with today's post but she is absolutely stunning. |
Evidence based medicine and
cultural competence in medicine are two key concepts most veterinary and
medical curricula are trying to accommodate simultaneously. However, there
seems to be a fundamental conflict between the two. I finally understood it
when I read an editorial in Health
Services Research by Romana Hasnain-Wynia, shared by Dr Martin Whiting.
First though, what does each
mean on its own?
Evidence-based medicine (EBM
to those who know it well) is the “conscientious, explicit and judicious use of
current best evidence, primarily from clinical trials, in making decisions
about the care of individual patients” (Hasnain-Wynia, 2006).
Skittles looks like she has a Batman mask. |
EBM is associated with
diagnostic and treatment guidelines, algorithms and protocols. The aim is to
standardise patient care. Overall that seems to be a good thing. It means
treatment decisions aren’t based on the whims or limitations of one
practitioner.
There are a few limitations
of this approach. The gold standard of evidence is the randomised controlled
trial, but they can be an ethical minefield. For example, subjecting a patient
with a particular condition to sham surgery to compare to those receiving a
surgical treatment may have an unacceptable welfare cost. So some trials just
don’t happen.
Skittles walks on a lead. |
EBM is only as strong as its
evidence-base, the size of which can be variable. Veterinary trials are
relatively thin on the ground, and when they do exist they usually consist of
small numbers of animals (with the exception of some large scale, multi-centre
studies). Sometimes all we have to go by is a case series or, gulp, a case
report. Or extrapolation from first principles. Or asking an expert.
And there are some
treatments for which observational studies are convincing enough. Smith (2003) makes
this point rather colourfully in a paper suggesting that “the most radical
protagonists of evidence based medicine organised and participated in a double
blind, randomised, placebo controlled, crossover trial of the parachute” (see
the article here).
And again. So its hard to focus on a moving ferret. |
Cultural competence in
medicine (CCM) is “the delivery of health services that acknowledges and understands
cultural diversity in the clinical setting and respects individuals’ health
beliefs, values and behaviours” (Hasnain-Wynia, 2006).
It emphasises finding out
what is important to the patient. The emphasis is on individualisation, rather
than standardisation, of care.
Of course it can be misused,
leading to cultural stereotyping, which can be harmful to individual patients
and populations. The emphasis of CCM has shifted from providing specific
knowledge about certain cultural groups and minorities to promoting humility,
communication, understanding patient narrative and so on.
The problem is that EBM and
CCM both base recommendations on modal information from studies populations or
subgroups – so critics might argue that their recommendations either don’t
apply broadly enough or marginalise some individuals. The classic criticism if
EBM is that it promotes “cookbook” medicine, a one-size-fits-all approach. The
classic criticism of CCM is that, at its worst, is promotes cultural
stereotyping.
The real questions are
these: can EBM provide patient-centered care? Can CCM demonstrate improved
clinical outcomes? And if they do, how can we tell? It can be challenging
measuring outcomes for either model (that doesn't mean we shouldn't try).
Skittles held. |
Hasnain-Wynia argues that
despite the evolution of EBM and CCM, we need to admit that EBM does promote
standardisation of care which leads to reduced discretion for clinicians and
patients. On the other hand, CCM promotes discretion for clinicians and
patients and may leader to greater variability in clinical care. And that is
okay. There is a need for both.
Whilst these are exactly the
issues that critics target, neither is inherently bad, and neither justifies
canning the whole theory (or as philosophers love to say, throwing out the baby
with the bathwater).
References
Hasnain-Wynia (2006) Is
evidence-based medicine patient-centered and is patient-centered care
evidence-based? Health Services Research 41(1):
DOI 10.1111/j.1475-6773.2006.00504.x