Evidence-Based Medicine: Opportunities and Challenges in a Diverse Society

Article excerpt

In this article we explore the discourse and practice of evidence-based medicine (EBM) in the context of social and cultural diversity. The article consists of 2 parts. First, we begin by defining EBM, describing its historical development and current ascendance in medical practice. We then note its importance in contemporary psychiatry, comparing dynamics between the United States and Canada. Secondly, we offer a constructive critique of the application of EBM and evidence-based practices in the context of ethnocultural diversity, as one consistent reflection on the EBM literature is that it is does not adequately address issues of diversity. In doing so, we use the situation here in Canada as an extended case study, though our observations will likely be applicable in other diverse nations, such as the United States, the United Kingdom, and Australia. We critically examine the following 6 issues related to the practice of EBM in a diverse society: generalizability and transferability of evidence-based interventions; diversifying standards of evidence in EBM; strategies to address diversity in EBM research; cultural adaptations of evidence-based interventions; integrating idiographic knowledge; and, training and health service delivery. Concurrent with our critique, we offer research and practice suggestions that may address outstanding challenges vis-à-vis the practice of EBM in a diverse society. These include a need for more effectiveness research, more openness to diverse sources of knowledge, better integration of idiographic and nomothetic knowledge, and a critical approach to extrapolation and transfer of knowledge.

Can J Psychiatry. 2011;56(9):514-522.

Highlights

* The paradigm of EBM has not sufficiently addressed issues of social and cultural diversity. Our paper highlights implications of such deficits for clinical care and service delivery in the context of diversity.

* Our paper also highlights further research strategies to address knowledge deficits regarding the development and application of EBM in a diverse society.

Key Words: evidence-based medicine, evidence-based practices, diversity, ethnicity, race, mental health services

Abbreviations

CANMAT Canadian Network for Mood and Anxiety Treatment

CBT cognitive-behavioural therapy

EBM evidence-based medicine

EBP evidence-based practice

MHCC Mental Health Commission of Canada

RCT randomized controlled trial

SMI severe mental illness

SUD substance use disorder

The EBM movement arose out of concern that many patients were receiving ineffective treatments that were grounded in conventional practices, clinical intuition, or practitioner idiosyncrasies rather than scientific evidence.1,2 British epidemiologist Archie Cochrane was the pioneer par excellence of EBM, arguing that researchers must systematically evaluate each and every intervention through RCTs to determine their true efficacy.3,4 Only those interventions shown to have significant and consistent effects on outcomes through accumulated RCTs would then be labelled evidence-based. Health providers and planners could then work to make these interventions readily available.5

Cochrane's ideas reached a wider audience through the seminal work of Canadian researchers, led by David Sackett and Gordon Guyatt at McMaster University.6 Their work in the 1980s and 1990s solidified the place of EBM in medical care. In a seminal paper, they defined EBM as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."1, p71 The explicit mention of "judicious use" acknowledged that the practice of EBM meant integrating clinical expertise with the best available evidence from systematic research. In recent years, governments around the world have endorsed EBM as a desirable basis for health care services, with the rationale that, in the context of limited resources, public money will be better spent on interventions with proven effectiveness and efficacy. …

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