Is it time to end the tyranny of evidence based practice?

Perhaps the greatest mind in the entire history of the world – well in my estimation anyway – once argued that it is the the things that are the most obvious and seemingly benign that we should focus all of our critical attention upon, because these are the things that are doing the best job of concealing the immense power that allows them to become so seemingly obvious in the first place.  (If you hadn’t realise already, that man is Michel Foucault).

Well of all the seemingly obvious, taken-for-granted and largely unchallenged ideas currently pervading physiotherapy, evidence based practice must surely be one of the most obvious ideas needing critical scrutiny.

Fortunately, a few physiotherapists are raising their heads above the parapet to challenge the primacy of EBP, evidenced by the latest editorial in Physiotherapy Canada (link).

In this editorial, the authors raise some of the limitations of EBP, most notably its lack of any acknowledgement of ethical decision-making, proposing the following new definition: EBP is ‘an area of study, research, and practice in which clinical decisions are based on the best available evidence, integrating professional practice and expertise with ethical principles’ (Veras, Kairy & Paquet, 2016, p.95).

The authors correctly point out that ‘Several authors have criticized EBM methods, which they see as an attempt to monopolize science for standardizing methods and research tools around a unique scientific truth’ (ibid), and it’s refreshing to see them argue for EBP to be situated within a more contemporary social context.  But in my view their argument is weakened by the fact that they promote a newer, shinier, better form of EBP, rather than asking radically critical questions about its purpose and principles.

In recent years, a number of authors have offered significantly more critical commentary on EBP.  Spence recently claimed that ‘Today EBM is a loaded gun at clinicians’ heads. “You better do as the evidence says,” it hisses, leaving no room for discretion or judgment. EBM is now the problem, fueling overdiagnosis and overtreatment’ (Spence, 2016), whilst Trisha Greenhalgh et al argued that ‘The evidence based “quality mark” has been misappropriated by vested interests’ (Greenhalgh et al, 2014).

David Sackett himself identified that it was impossible for health professionals to keep pace with the volumes of information now available to them, and Madjar and Walton acused advocates of EBP of ‘dehumanising medical reductionism’ (Madjar & Walton, 2001).

Goldberg argued that ‘Relying on ‘‘the facts’’ or ‘‘the evidence’’ to adjudicate between competing clinical practices or scientific beliefs assumes that the evaluative standards of EBM are transparent, neutral, objective, and universal. The numerous accounts of scientific knowledge as ‘‘situated knowledges’’ (Haraway, 1988) offered by post-positivist, feminist, and phenomenological thinkers suggest that this understanding of evidence is far too simple and no longer a tenable position in science studies’ (Goldenberg, 2006: 2630).

But perhaps the most damning criticism of EBP comes from one of the journals that has spent more than 15 years presenting the latest evidence-based literature.  In a 2008 editorial in the Journal of Evaluation of Clinical Practice, the authors argued that;

‘We view with no small dismay and profound disappointment the continued refusal of the protagonists of EBM to engage in formal intellectual exchange, a position which represents nothing more than the long maintenance of an unscientific and antiscientific posture which we have come to interpret as a pragmatic mechanism designed to protect the cherished ideological convictions of the EBM community.

‘If these colleagues view their settled positions as intellectually defensible and morally justifiable, then why are they so utterly opposed to confronting their critics? Why do they recoil from entering the intellectual forum of the JECP…in order to justify the generalities and specifics of their thesis, if they believe them to be so eminently justifiable?

The editors go on to accuse the proponents of EBM of ‘extraordinarily lacking in intellectual credibility’ of being ‘profoundly revisionist and demonstrat[ing] that little has changed in terms of EBM’s ideology or hubris with the exception of an increase in self-delusion and a refusal to accept that EBM is ‘finished’ in scientific, philosophical and clinical terms’ (Miles, Laughlin & Polychronis, 2008, pp. 621-2).

A few weeks ago, I gave a talk in Norway on some of the contemporary criticisms of EBP (there is a link to the full presentation here).  I had anticipated a rough ride, given that I had assumed no-one would want to hear a criticism of something that was such an important part of physiotherapy’s contemporary professional identity.  I was surprised to find, then, that the audience was more than receptive to the ideas.  Indeed, for some of them it only consolidated what they had already begun to ask themselves.

I wonder then if now is not the time to start agitating for an radically critical new approach to physiotherapy that does not perpetuate the kinds of dehumanising medical reductionism that caused Trish Greenhalgh to ask whether EBM was not now in crisis?

References

Goldenberg, M. J. (2006). On evidence and evidence-based medicine: Lessons from the philosophy of science. Social Science & Medicine (1982), 62(11), 2621-2632. doi:10.1016/j.socscimed.2005.11.031.

Greenhalgh, T., Howick, J. & Maskrey, N. (2014). BMJ; 348 doi: http://dx.doi.org/10.1136/bmj.g3725.

Madjar, I., Walton, J. A., Morse, J. M., Swanson, J. M., & Kusal, A. J. (2001). What is problematic about evidence. In The nature of qualitative evidence (pp. 28-45). Sage Publications Thousand Oaks CA.

Miles, A., Loughlin, M., & Polychronis, A. (2008). Evidence-based healthcare, clinical knowledge and the rise of personalised medicine. Journal of Evaluation in Clinical Practice, 14(5), 621-49. doi:10.1111/j.1365-2753.2008.01094.x.

Spence, D. (2016). Evidence based medicine is broken. http://www.bmj.com/content/348/bmj.g22.

Veras, M., Kairy, D., & Paquet, N. (2016). What is evidence-based physiotherapy? Physiotherapy Canada, 68(2), 95-96.