Monday, July 13, 2015

What is evidence-based veterinary medicine and what does it look like in practice?

Do you know which literature  to consult and how to critically appraise it?
Have you ever wondered what evidence-based medicine is, or what it looks like in veterinary practice? We all use evidence on a daily basis, and often make a judgement about the quality of that evidence. But how sound are those judgements?

Dr Nick Royle works for the Royal College of Veterinary Surgeons in the UK. He took some time out to explain his role and the nature if evidence-based veterinary medicine (EBVM).

What is your role within the RCVS?

I’m the Executive Director of RCVS Knowledge. Formally the “RCVS Trust”, we’re the independent charity partner of the UK’s Royal College. We have a threefold mission: to manage the College’s Historical Collection; to maintain and grow a (principally online) technical library on behalf of the practising veterinary community; and to forward the relatively new concept of Evidence-based Veterinary medicine (EBVM).

I came to RCVS Knowledge having led TheCochrane Collaboration for nine years as its first CEO, and previously to the “evidence led” movement from having tried to adopt this approach for drug and alcohol services in Scotland prisons whilst serving as their first Head of Addictions.

Dr Nick Royle.
The role of RCVS Knowledge within EBVM is to bring together those pockets of activity – and there are some really great teams out there working on this – and through international networking ensure that the whole really is greater than the sum of the parts. Together, we can do something really special.

What, in a nutshell, is EBVM?

EBVM is the conscious use of best available evidence to support clinical decision-making. Derived principally from the synthesised conclusions of the best available scientific evidence, such evidence should be used in conjunction with the practitioner’s experience, patient circumstances, and owners’ values.

EBVM is "new" in veterinary medicine but is it possible that many of us are already using it without really knowing it?

More than likely, to different degrees. There are many great vets, and any good vet will be making sure that their decision making is science-based. But an evidence-based approach takes this to another level, and is, if you like, a different mindset. Yes, you might have read the latest paper on the condition – but where did that paper sit within the greater context of what we know about the condition? Was the trial or study on which it was based well conducted, free from bias, and of sufficient “power”? So an evidence-based approach is about being questioning, and open to changing your practice in the light of your new knowledge.

One of the problems with evidence in any field of medicine today is that it is often presented by companies that manufacture or distribute a product, with a vested interest in its sales. Is some evidence more trustworthy than other evidence?

Some years back, when I was running a drug testing programme, a company tried to sell me a urine testing kit. The salesman provided me with a research paper that he reassured me showed how good his kit was. I read the paper, and it said that his kit wasn’t as good as other kits available.

I guess the salesman had never read his own stuff, and the moral of the story would be that we should always be wary of a single research paper, and that we need to place such information within the wider context of what is known about the question being asked.

This is where the type of evidence-based approach we advocate really pays off. By “evidence” we don’t just mean the results of a single paper, and we certainly don’t mean compiling a range of clinical test results. We mean synthesised evidence drawn from the collated results of all the trials or studies relevant to the question we are asking.

The evidence-based approach has a number of steps:
  1. Work out what your question is – the more defined the better.
  2. Track down the best available evidence – perhaps using the RCVS Knowledge online library (and maybe our information specialists to help).
  3. Critically appraise the evidence you find. How up-to-date is it; are the trials on which it is founded well conducted; is there any bias in the trials or how they are reported, and is this relevant?
  4. Apply what you have found to your decision-making process.
  5. Evaluate how things turned out.

What does EBVM look like in the context of veterinary general practice, i.e. how does a practice where vets using EBVM differ from one where they don't?

An evidence-based approach has revolutionised clinical care in human health. Doctors have stopped doing many things that are ineffective or dangerous, become more conscious of price differentials between equally effective products, and through clinical guidelines applied this knowledge widely throughout their profession. Very often with no idea that they are being “evidence based”.
We share the view of many within the veterinary profession that it’s time for a similar “quiet revolution” here.

One of the most difficult questions I am asked by young vets-in-training is what do they do if they get to their first practice with all their hard-won knowledge, and find that people aren’t welcoming of new-fangled ideas and that “they don’t do that here”.

The sign of a good practice is surely one where the veterinary team are questioning and open to new ideas; where cases are discussed amongst colleagues, and new concepts considered carefully and where appropriate embraced. That would be an evidence-based veterinary team.

Thank you Dr Royle for taking the time to answer our questions. If you’d like to learn more about EBVM and you’re based in the UK (or plan to pop over there in the near future), the RCVS Knowledge is running the first EVBM Skills Day: Essential Tools for Evidence Based Practice.

The program, which you can view in full here, looks absolutely fantastic.

Topics covered include how doctors make decisions, how to design a study in practice, how to critically appraise a paper and run a journal club, significant event and clinical auditing and evidence-based veterinary management.