Sunday, 29 January 2012

Evidence Based Healthcare

One of my intentions with this blog was to sift through the evidence base for health promotion, and therefore strengthen my knowledge base and the underpinning of my medical education, which has been focussed on patient-centred communication, often to the detriment of biomedical knowledge. There are only so many hours in a week and only so many lectures one can endure. My entire medical education has been undergirded by the idea of patient-centred care, and I value the idea of treating someone holistically, using the previously mentioned biopsychosocial model for determinants of health and disease. However, over the past few decades, the idea of using evidence to separate benefit from harm in interventions has also come to fore, and so I wondered what evidence there was for such care.

What I've found, however, is that there's practically no evidence for holistic or patient-centred care. All of the data I could find said that more research is needed. This is not to say it's a worthwhile goal in itself, but we don't know whether it promotes health, causes bad outcomes, or whether it makes no difference whatsoever. Why are we being taught this in an era of Evidence-Based Medicine? Perhaps because it makes intuitive sense. Caution must be advised, however, when it comes to intuition and medical science. For years, medicine caused great harm by basing its practice on an intuitive approach, where the 4 humours were thought to be out of balance in disease, and led to such practices as bleeding and induced emesis, not to mention harmful potions full of toxic substances. I'm talking about 100 years ago, not modern pharmacology nor the stupidity of anti-vaccinators.

Intuition is a great tool in the practice of healthcare, where the practitioner takes all of his or her knowledge and experience, and combines it with observations about the patient's demeanor, dress, and maybe even their surroundings if on a home visit. Indeed, much of the therapeutic nature of nursing and medicine lies outside the scope of pharmacotherapeutics and borders "dangerously" on the realm of psychosocial interaction, which also feeds into intuition. An article (behind a paywall, unfortunately for seekers of free knowledge) decries the idea that medicine is even a branch of science and suggests that perhaps it's an applied science with more tinges of the humanities than many in the field would care to admit.

So what conclusions can we draw from this seeming paradox of intuition and evidence being the edges of a sword which separates real medicine from charlatanism, yet at the same time seeks to separate the practice of effective health promotion from dispassionate biomedical models of disease? I can appeal to neither my scientific training nor to my intuition for the answer, for they will both lead me down their biased pathways. Instead, perhaps I must use each in their turn, seeking a balance between the two, where intuition is guided by science, and the scientific application of biomedical knowledge is placed within the context of the person's whole condition. Is this what holistic care is, and if so how do we measure the outcome? Is merely feeling good about the care we give or receive enough evidence? Clearly not, otherwise we would still be indiscriminately bleeding people with leeches.

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