In Practice OC TOBER 2008 526

DEVELOPMENT OF
EVIDENCE-BASED MEDICINE
Assumptions
Evidence-based medicine, as a spe-
cific entity, can be traced back to
the statement of the Evidence-based
Medicine Working Group in 1992
(Guyatt 1992) that provided four
explicit assumptions for a new para-
digm of medicine, developed from
the principles of clinical epidemiol-
ogy and the groups experiences of
introducing a new medical course
at McMaster University in Canada.
These were as follows:
Clinical experience and the
development of clinical instincts
are a crucial and necessary part of
becoming a competent clinician, as
many aspects of clinical practice
are not and never will be evidence-
based;
The study and understanding of
the basic mechanisms of disease are
a necessary but not sufficient guide
for clinical practice;
An understanding of the rules
of evidence is necessary in order to
correctly interpret the literature on
causation, prognosis, diagnostic tests
and treatment strategy, leading to a
requirement for the development of
critical appraisal skills;
Those physicians whose practice
is based on an understanding of the
underlying evidence will provide
superior patient care.
A five-step approach
Despite the fact that these under-
lying assumptions have been
re peated on many occasions, evi-
dence-based medicine has come to
be associated most strongly with the
explicit use of research literature in
making decisions about the care of
individual patients. This explicit
use of research evidence has been
developed into a five-step approach
(Sackett and others 1998, Cockcroft
and Holmes 2003):
Convert information needs to
answerable questions;
Track down, with maximum effi-
ciency, the best evidence with which
to answer these questions;
Critically appraise the evidence
for its validity (closeness to the
truth) and usefulness (clinical appli-
cability);
Apply the results of this appraisal
to clinical practice;
Evaluate performance.
Research shows that, even in
the medical profession with all the
resources available through the
National Health Service, evidence-
based medicine is not being prac-
tised in the explicit way originally
envisaged; instead, the tenets of evi-
dence-based medicine are becoming
absorbed into practice in more tacit
ways (Gabbay and le May 2004).
KNOWLEDGE AND
EVIDENCE
Despite all that has been written on
evidence-based practice in all its
forms, there has been surprisingly
Applying evidence-based
veterinary medicine
In Practice (2008)
30, 526-528
VETS are increasingly being encouraged to ensure that their
practice is evidence-based, partly due to changing attitudes to the
professions and increased requirements for public accountability.
Practice should also be evaluated regularly, in the light of new
research, to ensure that the best care is being provided. Sally Everitt
looks at some of the options for integrating the tenets of evidence-
based medicine into veterinary practice, and identifies some of the
challenges.
SALLY EVERITT
little on the status of evidence. The
problem of knowledge has taxed
phil osophers and others for centu-
ries, and the scientific method has
come to be seen as the best method
for creating new knowledge (Cohen
and Nagel 1934). However, as our
techniques have become more
sophisticated, we have come to real-
ise that even scientific knowledge
has its limitations, and that when
dealing with biological systems with
their inherent variability, the best
we can achieve is knowledge that is
probably true and in which we can
have high confidence (Wulff 1990).
Knowledge has been defined as
justified true belief (Ayer 1956).
In this case, evidence becomes the
justification with which we support
our belief; however, evidence does
not stand alone but rather, in a legal
analogy, it must be judged. Once we
accept evidence as something that
can, and should, be judged, it is possi-
ble not only to include a much broad-
er range of evidence but also reinte-
grate clinical judgment and expertise
into evidence-based practice.
Types of evidence
Within human medicine there is
a well-recognised hierarchy of
evidence, in which randomised
controlled trials (RCTs) and, more
particularly, systematic reviews
and meta-analysis of numbers of
these trials form the best evidence
(Anon 2001). Unfortunately, in vet-
erinary medicine, this information
is un available, so we need to widen
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Sally Everitt
graduated from
Bristol in 1981 and
has spent most of
her working life in
practice. In 2007
she gained an
MSc in veterinary
general practice.
She is currently
undertaking
research towards a
PhD at the University
of Nottingham,
studying clinical
decison making in
veterinary practice.
In Practice OC TOBER 2008 527
our search for evidence and, in each
individual case, make an assessment
of the strengths and weaknesses of
the evidence available (Cockcroft
and Holmes 2003).
Tonelli (2006), in proposing a
casuistic or case-based alternative
to evidence-based medicine, recog-
nised five different types of infor-
mation that all need to be considered
when making a decision:
Empirical evidence, derived from
clinical and basic research;
Experiential evidence, derived in
the course of practice by clinicians;
Pathophysiological rationale;
Patient goals and values (or, in
the veterinary case, client goals and
values);
The circumstances in which the
treatment is being carried out.
JUDGING THE EVIDENCE
Evidence-based medicine gives clear
guidelines on how evidence should
be judged, both in terms of the
hierarchy of evidence and through
critical appraisal of research papers.
However, the only way it can deal
with non-empirical evidence is to
consider it as low-value informa-
tion that should only be used when
research evidence is not available.
Tonelli (2006) considered this to
be a mistake, suggesting that the
evidence from clinical experience,
pathophysiology and client values
are different in kind, not just degree,
from that achieved by experiment,
and all need to be considered and
evaluated when making clinical
decisions. If we accept this posi-
tion, we need to find an alternative
method of judging the different
types of evidence available to us.
The usefulness of medical infor-
mation has been defined as its
relevance x validity/work to access
(Shaughnessy and others 1994),
where relevance relates to its appli-
cability to the patient, validity to
its closeness to the truth and work
to access to the effort to find and
interpret the information. While
empirical evidence is likely to score
highly on validity, clinical experi-
ence in practice may well be more
relevant to a particular case. In
order to provide the best evidence to
support our clinical decisions in prac-
tice, we need to maximise the useful-
ness of the information we have.
Relevance
As a profession, we have to accept
that we will never have the finances
that are available to the medical pro-
fession, either to support research or
build evidence-based resources, so
it is important that we use those we
have wisely. We need to ensure that
the experimental evidence produced
is of maximum relevance to our
patients. RCTs are important here
as they usually include naturally
occurring cases, although they are
not without their problems and need
to be well designed and of sufficient
size to ensure maximum validity.
They are also more suited to com-
paring medical treatments than
surgical procedures, as differences
between surgeons are likely to have
a significant effect on the outcome
(Innes 2007).
It is also important that we con-
centrate on outcomes that are rel-
evant to our clients and patients; for
example, Wiseman-Orr and others
(2004, 2006) developed a question-
naire to assess the effect of chronic
pain on dogs quality of life, which
enables the owners observations
and information about the dogs
activity and behaviour to be included
systematically in assessments of
response to treatment.
Validity
Individually and collectively we hold
a huge amount of evidence on how
to practise, but much of it is neither
recorded nor validated in any way.
While our clinical experience is
often a valuable guide to practice, it
is not immune from problems; lapses
of memory and bias (particularly the
tendency to seek out opinions and
facts that support our own opinions)
can often mislead us (Croskerry
2002, Greenhalgh 2002). To make
the best use of our collective clini-
cal expertise, we need to be able to
Glossary
Casuistry
Case-based reasoning emphasising the importance of the
individuality of the case over theoretical principles
CAT
A summary of the research evidence pertaining to a particu-
lar clinical question.
Clinical audit
The systematic review of clinical performance and the refin-
ing of clinical practice as a result of measuring performance
against agreed criteria
POEM
Patient-oriented evidence that matters. Summary of the
clinically relevant information from a research paper or
systematic review
Protocol
Written step-by-step guidance covering a particular aspect
of clinical care. It should be developed locally by a clinical
team based on the best available evidence, as well as the
availability of resources and policy decisions within that
team. By implication it is expected that a protocol will be
followed rigorously although it may make provision for
expected variations
Relevance
The applicability of the information to the individual case
Research
A systematic investigation that aims to increase the sum of
knowledge or generate new knowledge
Validity
The extent to which the test or trial measures what it sets
out to evaluate
At present, primary literature in peer-reviewed veterinary journals is the main
source of evidence available to practitioners
In Practice OC TOBER 2008 528
systematise and share it. The first
requirement will be finding methods
that enable data to be collected and
compared between practices.
Clinical audit can be used as
a starting point for practices but,
unless consistent ways of record-
ing and recalling data can be found,
comparison between practices will
remain difficult. Several groups have
applied standardised medical nomen-
clature to veterinary practice without
success, and have gone on to devel-
op their own, more workable, sys-
tems. Recently, groups at the Royal
Veterinary College and Glasgow
University have agreed to amalgamate
their systems. The combined system
is now being tested in a few prac-
tices using RxWorks software and
will soon be included in VetSolutions
practice management systems (S.
Godsall, personal communication).
Once we have accurate ways of
recording and accessing the data
from practice, we open the way to
building evidence-based resources
relating to the epidemiology of dis-
ease, as well being able to compare
treatments and outcomes through
benchmarking and clinical audit.
This will enable us to monitor and
improve the care we provide to our
patients.
Work to access
Having produced the evidence, it
must be easily accessible to those
who will use it. At present, we tend
to rely on the primary literature in
peer-reviewed journals, as well as a
variety of non peer-reviewed grey
literature, to keep up to date. The
peer-review process has come in for
a certain amount of criticism, but,
as yet, no one has come up with a
better alternative (Harding 2002).
However, it has been suggested
that publication should only be the
beginning of the peer-review pro-
cess, and that technologies allow-
ing comment and debate on papers
after publication of information (see,
for example, www.bmj.com/chan-
nels/research.dtl) allow for a more
complete and open process of peer
review (Stang and others 2008).
However, for busy practition-
ers, even with the facilities of the
RCVS library, keeping up with and
appraising the literature is a time-
consuming process. We therefore
need to develop ways of making
the most clinically relevant mater-
ial easily available to practitioners.
While there may not be sufficient
RCTs to undertake a formal meta-
analysis or systematic review of an
area, the types of narrative review
in, for example, In Practice, can be
expanded to include the evidence
on which they are based, thereby
giving the reader the opportunity to
appraise them more fully. Evidence
from research can also be made
available to practitioners through
evidence-based protocols and guide-
lines, critically appraised topics and
patient-oriented evidence that mat-
ters, which all aim to provide evi-
dence in a more easily assimilated
form.
IS EVIDENCE-BASED
VETERINARY MEDICINE
POSSIBLE?
Evidence-based veterinary practice
is at a much earlier stage in its devel-
opment than evidence-based medi-
cine and, when comparing to the
resources available, it may appear an
impossible undertaking. If we aspire
to practising the explicit form of evi-
dence-based medicine using system-
atic reviews of large, well-conducted
RCTs, we are likely to become dis-
illusioned. However, other profes-
sions, such as physiotherapy and
nursing, have been able to apply
the tenets of evidence-based prac-
tice by taking a broader approach
to evidence and realising that prac-
titioners themselves have to become
involved as producers as well as
consumers of evidence. Initiatives
such as the Cambridge Outreach
Program to involve practition-
ers in research, the British Equine
Veterinary Association surveys
into the treatment of laminitis and
colic, and the Society of Practising
Veterinary Surgeons How do you
treat? project to collect data on how
practitioners undertake certain pro-
cedures, provide us with a starting
point and the opportunity to share
information between practices. It
is only by working together that we
will be able to build the evidence-
based resources that we need.
Finally, we must be careful not
to overemphasise the necessity for
research evidence or, in those areas
where we do not have any, we will
be in danger of undermining the
credibility of our practice. We need
to remember that evidence, whether
derived from peer-reviewed journals,
expert opinion or our own experi-
ence, does not in itself provide suffi-
cient reason for our practice rather,
it has to be collected, appraised and
judged using our clinical expertise
before it can be integrated into the
service provided to clients and the
care provided for patients.
Acknowledgements
The author would like to thank
her supervisors at Nottingham
University Malcolm Cobb,
Alison Pilnick and Justin
Waring for their help and
advice in preparing this article
for publication.
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