Academic journal article Health Sociology Review

Cochrane Reviews and the Behavioural Turn in Evidence-Based Medicine

Academic journal article Health Sociology Review

Cochrane Reviews and the Behavioural Turn in Evidence-Based Medicine

Article excerpt

Evidence-based medicine (EBM) has been one of the most important social movements in clinical medicine and public health in recent years (Pope, 2003; Traynor, 2000). A term first coined by a group of clinical epidemiologists from McMaster University in Canada in 1992, EBM was announced with considerable fanfare as a new paradigm for medical practice (Mykhalovskiy & Weir, 2004). According to its supporters, EBM provided an approach to clinical activity that would save the practice of medicine from many of its major ills, moving beyond individualised and irrational decision making towards a careful review of the best available research evidence (Cohen, Stavri, & Hersh, 2004; Cronje & Fullan, 2003; Mykhalovskiy & Weir, 2004).

At the heart of the EBM movement lies the Cochrane Collaboration (Cohen et al., 2004; Traynor, 2000), an organisation named after Archie Cochrane, a 'maverick' British epidemiologist who advocated the use of randomised controlled trials (RCTs) as a means of informing healthcare practice (Greenhalgh, 2004). According to its website, the Cochrane Collaboration is:

[D]edicated to making up-to-date, accurate information about the effects of health care readily available worldwide. We are world leaders in evidence-based health care. Our contributors work together to produce systematic assessments of healthcare interventions, known as Cochrane Reviews ... [which] are intended to help providers, practitioners and patients make informed decisions about health care, and are the most comprehensive, reliable and relevant source of evidence on which to base these decisions (Cochrane Collaboration, 2010).

As their website states, Cochrane reviews are the central activity of the Cochrane Collaboration. Using a prescribed process and methodology, reviewers scrutinise the published literature to determine its quality and summarise (and where possible conduct meta-analyses of) the evidence of efficacy of a variety of healthcare interventions.

Despite the widespread embrace of EBM, trenchant attacks of the movement and its underlying tenets have been launched within medicine and beyond it. I do not intend to retread the critiques here, which are by now well known, except to say the movement has been attacked on a wide variety of fronts, from its philosophical underpinnings, methodological flaws and anti-humanist 'one size fits all' orientation, to the ways EBM principles align with the neoliberal restructuring of the welfare state and the rationalisation of healthcare services it has engendered (Cohen et al., 2004; Goldenberg, 2006; Holmes, Murray, Perron, & Rail, 2006; Lambert, 2006; Little, 2003; Mykhalovskiy & Weir, 2004; Rodwin, 2001; Tonelli, 1998; Upshur, 2002; Webb, 2001). However, with some notable exceptions, the critiques have tended to be primarily abstract and philosophical (Mykhalovskiy & Weir, 2004).

This paper takes up Mykhalovskiy and Weir's (2004) call for social scientists to conduct empirically grounded examinations of EBM's use through an in-depth examination of one particular Cochrane review. As Mykhalovskiy (2003, p. 332) notes: 'The texts of EBM offer important points of entry for an inquiry of the social practices through which EBM is organised as a governing project, yet they have been scarcely researched'.

EBM 'CREEP'

Despite the numerous critiques of EBM, they have not had a noticeable impact on its status amongst government agencies and healthcare organisations. As Goldenberg (2006) notes, EBM has a ring of obviousness to it. As an instrument of accountability, in principle EBM is almost impossible to challenge. In the words of Little (2003, p. 177), 'the argument for EBM is strong; irrefutable, in fact. It would be both immoral and irrational to use treatments that were not strongly supported by the best evidence'. This self-evident value has therefore enabled the creep of 'evidence-based practice' (as the movement has become more broadly known) into domains outside of clinical medicine. …

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