On Evidence-Based Medicine

by Mike Clarke

he surest prediction about what evidence-based health care will look like in a few years, as both a research endeavor and an influence on peoples’ lives, is that it is unpredictable. In making health care decisions, however, we have little choice but to make predictions. Which painkiller will get rid of this headache quickest? Does that sprained ankle need to be x-rayed? What other treatments could be used to lower blood pressure if this drug doesn’t work?

Health care is full of questions, and my prediction—and hope—is that it will be increasingly full of answers. Furthermore, these answers will be based less on opinion and more on reliable evidence: knowledge derived from high quality research that is blended with the clinical judgment of the health-care provider and the values of the patient.

Picture the scene: a busy general practice in 2012. The power of knowledge has been harnessed to the power of electronic-information storage. As the patient’s symptoms are entered into the general practitioner’s computer, it draws on his history to suggest possible diagnoses. It also draws on reliable research evidence to rank the likelihood of these diagnoses and to highlight questions or tests that the GP might ask, or do, to help reach a decision. With a decision reached, the computer draws on knowledge about the problem’s seriousness and the likelihood of its clearing up on its own. Available treatments are suggested and their likely benefits and harms described. If there is uncertainty about the best treatment, there is an option to enter a research study, randomly assigning the patient to one of these treatments and collecting future information about his health to inform future decisions.

The computer doesn’t make decisions for the patient and doctor; it organizes and provides knowledge for them to draw on. In the future I look forward to this knowledge will come from independent, systematic reviews of research. Individual research projects are so numerous that trying to tap their separate findings when making a decision would be almost impossible. What people need, and what the knowledge broker of the future will provide, is a summary of existing research studies that appraises their quality and summarizes their evidence. This knowledge won’t just be on the GP’s desk; it will be everywhere that health-care decisions are made.

Although in life we often feel overwhelmed by information, in health care we already have the means to take a vast amount of information and distill it into the pure knowledge that we need. Even more attractive, there is no reason the patient might not be able to use similar tools at home, to help decide on the need to see the GP and to weigh the different treatment options.

What of the more distant future? What will health care be like when Wiley celebrates its 250th anniversary in 2057? I am confident of one thing: we will still fall sick and need treatment. The world of evidence-based health care then may be one in which our individual values and preferences for different outcomes and interventions are already known, stored on a chip under the skin of our little fingers to allay concerns about privacy and illicit access. Visits with health-care providers will begin with a scan of this chip so that the knowledge system can suggest appropriate options, one being a specially tailored trial comparing the two most suitable. The patient will have been able to consider this trial in advance through her home computer. If she accepts the trial, she will be randomized to an intervention, and her response to the treatment will be captured at future visits and used to help improve the knowledge base.

Knowledge is power, and when it comes to health-care decisions, what better place to have that power than at—if not in—the fingertips of those affected by these decisions, and of the people who care for them?

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