About Evidence Based Medicine - EBM
By Nora Laubstein, ANME (translation: Carl Classen)
The EU-bureaucracy in Brussels and Strasbourg is not prejudiced against Complementary and Alternative Medicine-CAM; scepticism and safety of the EU-consumer dominate the opinions. Nevertheless, there also is a big lack of knowledge of the traditional diversity or even personal experience.
To remove this deficit and as a base for argumentation we crucial need a guideline catalogue emphasizing CAM and e.g.“ExBM”, which will enable us to produce a comprehensible documentation of what we do every day for the wellness of our patients. Further we need a EBM comparable foundation including education, profession, medication and therapy.
This most extensive work could be produced by a commission which is authorized equiped personally as well as financially from the professional organisations and other stakeholders.
The term EBM wanders through the world of health policy, medicine d medical products since almost twenty years. Anyway it is older and its origin can be traced back to the 19th century. In the last decades esp. professor Sacket from Oxford university has concerned himself with EBM.
In German the term “Evidenz” is used, which as a borrowed word can probably be translated best as “provabability”. Looking into the dictionary, we find the meanings:
Evidence: proof, result, show sth clearly, testimonial.
- “evidence based” can without judgement be understood as:
grounded in proofs, the facts are proved clearly visible for all.
The question arises, what the real context is between the “scientific nature” and the “evidence” of something, at least concerning natural medicine. CAM could find a base here (key word: criticism of natural science).
Prof. Sackett coined the term “Evidence Based Medicine” as an independent medical discipline. With that he gave a definition coming from the academical field and using scientifical vocabulary, argumentation and classifications.
His definition reads [here re-translation from German]: „Evidece based medicine is the most consciousness, explicit and reasonable way to make use of the best present external scientific evidence for making decisions in the medical care of individual patients.“ - Here the term “scientific” appears. Without this term it would not be a problem for CAM to accept EBM.
But what for has EBM been developed at all?
The user (Public Health practitioners, scientists, etc.) should be supplied with a help to achieve orientation in the jungle of different publications and possible therapies. Also a specific method has been developped which enables one to make use of EBM.
How does “evidence” look like in practice and how does the user proceed?
1. The five levels of evidence
from strongest evidence (a) to weakest evidence (e)
a. systematical assesment on the base of randomized controlled trials of hig methodologigal value
b. at least one trial of high methodologigal value
c. trials without randomisation (cohorte-, case- and control trials) of high methodologigal value
d. more than one not experimental trial of high methodologigal value
e. opinions and convictions of authorities and expert commissions
2. The concret way of proceeding:
|1||At the beginning is a concrete case||At the beginning a patient comes|
|2||with a definite question or problem||with pains|
|3||which enable to make literature enquiries||which I could find in some book|
|4||the literature is identified||I find the book matching the case|
|5||it is acknowledged criticallythere||I find an advice matching for my patient|
|6||and the result is converted into practical relevant advices, and||combine it with the given medicine|
|7||make use of it in the special case.||and give it to the patient.|
3. EBM-tools for therapy and diagnosis are the following:
- NNT (Number needed to treat) gives the number of patients, which should be treated over the duration of the trial to prevent a occurence.
- NNH (Number Needed to...Harm) gives the number of patients, which should be treated to produce undesirable side effects within this episode.
- The user is adviced to keep NNT and NNH in a reasonalbe proportion.
- PROVING OF RELEVANCE: Does it match to the practical situation? Does it match to the situation of the patient?
- Only a relevant result will be applied!
4. EBM should serve as a quality safeguarding action, which limits are clearly named:
- unambigous questioning is difficult!
- decisions are made under time pressure!
- wrong research results in wrong evidence!
- danger of rising costs in the health care systems!
- unknow terminology decreases the acceptance!
- all answers without proof of evidence are dropped (slip away)!
Evidence based guidelines for diagnosis and therapy are developed and used, which refer to the average case and stastistical standard. Individual formulations of a question cannot be covered by general guidelines.
In the last years EBM measure guidelines have been developed and redesigned for GPs, for nursing services, for quality controlled practices and hospitals.
EBM has become measure of everything and today our health care system cannot be imgagined without it.
We find the technical networking of all EBM actions realized in the so called telematic. The telematic provides the insurace card (Siemens company) throughout Europe, which guaranties quality of health care to the EU consumer, in this case the sick consumer, by means of general guidelines, from Oslo to Palermo.
The question of how to survive, becomes very urgent for natural medicine, CAM, traditional methods and their medicaments — no matter how this area is called:
Where is the place for “our” medicine, the traditionally proven CAM, in a EBM determined health system, which refers to the above mentioned criteria for assessment and use as the only possible ones?
Due to EU legislation CAM-medicaments and supplements have been subject to a strict re-evaluation. To understand the full consequence of EBM, it is neccessary to understand the steps that have been carried out until now as parts of a EMB process and now we can see where this path will lead to:
Every month there are news about juridical steps against European CAM therapists, who are defined as not educated in or do not work or prescribe according to EBM guidelines. Old established schools and the former transmission of knowledge could disappear.
It is most crucial to develop a CAM positioning towards EBM and to proceed in defining a position of our own!
Already we have several university courses of study in natural medicine as additional qualification – we even have the Msc in CAM! In the future, this diploma course of study could become the measure of all natural medicine therapy in Europe.
Similar as professor Sackett succided years ago to introduce a systematical method in the area of conventional medicine, now the representatives of professional CAM in Europe and in every single member state are challenged now: They should use all their forces to develop a contribution to, as we propose, “Experience Based Medicine”. This work has to be done (key words: criticism of scientific methodology, imagination, empathy, materialism, sponsored research, interdiciplinary, qualitative research) and this e.g. “ExBM” could take into consideration some advantages of EBM, it could develop CAM specifical criteria and thus contribute to a modern form of CAM, which is acknowledgded and appreciated in the EU institutions a well.