|Year : 2018 | Volume
| Issue : 2 | Page : 69-70
Evidence-based medicine: What does it mean to spine surgeon
Anil K Jain, Manish Chadha
Department of Orthopaedics, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi, India
|Date of Web Publication||2-Aug-2018|
Prof. Anil K Jain
Department of Orthopaedics, University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi - 110 095
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jain AK, Chadha M. Evidence-based medicine: What does it mean to spine surgeon. Indian Spine J 2018;1:69-70
Clinical practice is generally based on the foundation of training imparted and knowledge acquired during a residency program. Medicine is an evolving science; hence, a clinician has to update continuously. The updating of knowledge is through books in which knowledge generally is 5 or more years old or from scientific journals for the latest advances. The new innovations and path-breaking research are usually published in journals which allow clinicians to gain knowledge and experience about treatment and outcome for conditions not commonly encountered. The journals are resource materials to educate about newer researches in treatment modalities, their outcome, as well as compare outcomes with world authorities.
The research published in peer-reviewed journals becomes evidence. The clinical practice based on research evidence makes the treatment outcome predictable. How this evidence is applicable to given clinical condition is “artistic application of science” to alleviate pain.
The evidence-based medicine (EBM) is a term coined by Prof. Gordon Guyatt from Canada in 1990. EBM was described as “An attitude of enlightened scepticism towards the application of diagnostic, therapeutic, and prognostic technologies.” Later on it was refined as “The conscientious use of current best evidence from clinical care research in making health care decisions.” It means the use of current best evidence from clinical care research to health-care decision with expertise.
Three important components of EBM are (a) clinical circumstances, (b) research evidence, and (c) patient preference.
- Clinical circumstances: The presentations of the clinical circumstances of a patient raise multiple questions to be answered while imparting treatment. For example, should we use a short pedicle screw construct or a long construct for burst fracture of lumbar vertebrae? EBM approach involves (i) clear delineation of relevant clinical question and that may be raised based on given clinical circumstances (patient) which a clinician is planning to treat. The research question can only be raised for a population/patients or about intervention, which is compared on a well-defined outcome. Once a research question is raised we need to find out a scientific answer
- Critical appraisal of available evidence: This depends on comprehensive literature search and critical appraisal of available evidence. The availability of evidence is the key. If evidence is available, then only critical appraisal is possible. Even if evidence is available, we have to practice the art of search of literature and even if literature is retrieved, we have to perform critical appraisal (knowing scientific basis of evidence. For critical appraisal, one needs to be well versed with the hierarchy of evidence). The critical evaluation of published evidence is an art practiced over the years. We need to understand the difference between various types of studies such as meta-analysis, randomized control trial, cohort (prospective or retrospective) case–control study, case report, and editorials. We need to understand that poorly conducted randomized control trials may be worse than well-conducted cohort studies (prospective or retrospective). The bottom line is “do not believe anything or everything published in journals.” People may write anything but one should believe only if one is convinced that it was a well-conducted study with valid conclusions. Each article has to be evaluated on the basis of relevance of research question, study design to answer the research question, if the study has taken care of all potential bias and whether the results have been appropriately statistically analyzed to justify the conclusions
- Patient preference: Applicability of the research evidence in a given patient, i.e., patient value. The integration of clinical situation with the best available research evidence and finalize what is the best to treat given clinical conditions is patient preference and is evidence-based treatment or rational medicine or clinical expertise.
This raises the question “whether Indian surgeons are practicing EBM?” And what are the lacunae in practicing EBM. To practice EBM, we need to educate ourselves with the skills of defining the research question, searching the literature, and art of critical appraisal of the published evidence. The Association of Spine Surgeons of India and Indian Spine Journal is committed to the task. The availability of research evidence to be applicable for clinical conditions unique to India such as spinal tuberculosis and other infections, neglected spinal trauma and late presentation of spinal pathologies need to be generated and made available as published articles.
India is a country with contrasts. We, on one hand, have the best of health-care facilities available to 20% of population while at the other end very meager resources for the remaining 80%. The treatment method used in the best of centers may not be applicable for others facing and working in a limited resource environment. We have to conduct research in this direction. If each and every spine surgeon of this association starts documenting all their cases on a computerized software database, we can easily perform retrospective analysis and can pool data for uncommon conditions. The Indian Spine Journal is a platform to publish locally conducted research.
India is a vast country with huge patient population. We have to treat all patients. The research about the outcome in limited resource infrastructure need to be conducted so that evidence-based treatment can be provided to most of patients.
The basic tenet of research is a specific well framed research question with well-defined methodology, using proper valid instrument for observation, significant difference of observations, and conclusions (answer) of research question based on statistically significant outcome. Any manuscript with a clear research question, what is evaluated, how it is evaluated (basis to say good or bad), what is observed, whether the observation difference is significant or not (statistical method) and conclusion (which is the answer to the research question is publishable.Indian Spine Journal is ready to provide any help to anyone who desire so in this matter.
| References|| |
Sur RL, Dahm P. History of evidence based medicine. Indian Journal of Urology 2011;27:487-89.
Masic I, Miokovic M, Muhamedagic B. Evidence based medicine - new approaches and challenges. Acta Inform Med 2008;16:219-25.
Bhandari M, Jain AK. Evidence-based orthopedics: One step closer! Indian J Orthop 2011;45:3.
Jain AK. Research in orthopedics: A necessity. Indian J Orthop 2009;43:315-7.
] [Full text]
Jain AK. Innovations in orthopaedics: Hypothesis to publication. Indian J Orthop 2012;46:605-7.
] [Full text]