The Gap between What is Knowable and What We Do in Clinical Practice

Introduction

This chapter takes you through the rationale behind and my own reflections on why I became involved in research on the implementation of Evidence-based Medicine (EBM). For this, I have partly rewritten a joint paper on EBM into a first person narrative. The original paper is accepted for publication by the Journal of Evaluation in Clinical Practice (Swennen, Van der Heijden, Blijham, & Kalkman, in press). This chapter adds a more comprehensive description of what EBM aims at and why. In addition, it includes my thoughts and feelings at each step of my learning process.

I would not have been able to initiate or continue my research without the support of Dr. Geert van der Heijden, Professor Geert Blijham, Professor Yolanda van der Graaf and Professor Cor Kalkman; all having the University Medical Centre Utrecht (The Netherlands) as their (primary) affiliation. This means that in this chapter ‘I’ often will reflect ‘we’.

First, I will provide you with some information about my background. I graduated from Medical School at the Utrecht University (The Netherlands) in 2002 without ever having heard of EBM. (Nowadays, the curriculum of my Medical School comprises EBM). After Medical School I decided not to start my residency in Internal Medicine, because I felt I had to protect myself against the emotional burden of me wanting to become an oncologist. For me, being an oncologist would be all about providing the best care to patients, and pay even more attention to the ones that could not be cured. Hence, after much deliberation I chose to work for the Executive Board of the University Medical Centre Utrecht and became a non-practicing doctor. This allowed me to work on the crossroads of management and doctors, and inspired me to try to bring management and doctors together by solving misunderstandings that impeded collaboration. The Executive Board offered the opportunity to do an MSc on Healthcare Management, and so it happened that late 2003 I first heard about EBM during this MSc. I could not believe that until then I had been completely unfamiliar with EBM. During all my medical lectures and internships I never questioned to which extent the knowledge and skills I was taught were (or were not) evidence-based. I fully trusted the teachers, i.e. experienced doctors, to be right, just like my fellow students did. In other words, I was blind to whether the advice received from the teachers was authoritative (evidence-based) or merely authoritarian (opinion-based). So, for me, this was quite an eye-opener. Hence, I decided to do my Master Thesis on the implementation of EBM. This Master Thesis resulted in the joint publication and gradually evolved in my PhD-fellowship and an academic training in Clinical Epidemiology. My research and this chapter are about my aspiration to help doctors getting the evidence into practice.

So, I am a supporter of EBM, in that it concerns both Evidence and clinical Expertise to be crucial: The evidence only becomes valuable when clinical expertise guides its proper use in clinical practice. Therefore, I think the name EBM and some reporting (in science and teaching) are rather unfortunate, because of their focus on the evidence part. It is completely understandable that this still causes many medical students and doctors to conclude that EBM is decontextualized from real life clinical practice; or is all about certainty; or that clinical expertise is considered less important.

I believe that all doctors want the best for their patients, and therefore deserve further help to become better able to actually do so. In time I hope my PhD fellowship will render helpful solutions that will enable and inspire doctors to further improve patient care.