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Evidence-based medicine: a commentary on common criticisms.
Discussions about evidence-based medicine engender both negative and positive reactions from clinicians and academics. Ways to achieve evidence-based practice are reviewed here and the most common criticisms described. The latter can be classified as ”limitations universal to the practice of medicine,” ”limitations unique to evidence-based medicine” and ”misperceptions of evidence-based medicine.” Potential solutions to the true limitations of evidence-based medicine are discussed and areas for future work highlighted.
Evidence-based medicine has been defined 1 as ”the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions.” The reader will immediately recognize that this is not a new process — clinicians have always striven to combine their clinical expertise and their patients‚ values with the best available evidence. However, interest in evidence-based medicine has grown exponentially since the coining of the term in the early 1990s 1 , 2 (from 1 MEDLINE citation in 1992 to 2957 in February 2000) and has led to calls to increase the teaching of evidence-based medicine at the undergraduate and postgraduate levels. 3
Evidence-based medicine is a multistep process ( Table 1 ). 4 Clinicians can incorporate evidence into their practices in 3 ways. First is the ”doing” mode, in which at least the first 4 steps in Table 1 are carried out before an intervention is offered. Second is the ”using” mode, in which searches are restricted to evidence sources that have already undergone critical appraisal by others, such as evidence-based guidelines or evidence summaries (thus skipping step 3 in Table 1 ). Third is the ”replicating” mode, in which the decisions of respected opinion leaders are followed (abandoning at least steps 2 and 3). Of course, even clinicians trained to the ”doing” level move back and forth between these modes, typically depending on whether they are dealing with clinical problems they encounter frequently or only rarely.
Discussions about evidence-based medicine engender both negative and positive reactions from clinicians and academics, and this paper describes our efforts to categorize and respond to the most common criticisms.
Criticisms of evidence-based medicine were systematically sought through an electronic literature search, from published surveys of front-line clinicians, 5 , 6 , 7 , 8 , 9 , 10 and from the written records of questions posed during seminars held around the world from 1994 to 1999 by the director of the NHS Research and Development Centre for Evidence-Based Medicine in Oxford, United Kingdom ( http://cebm.jr2.ox.ac.uk ) (Dr. David Sackett, personal communication, 1999). MEDLINE was searched (without language restrictions) for articles published from 1966 to 1999 using the following search strategy: ”evidence-based medicine” [MH] OR (”evidence-based” [TW] AND ”medicine” [TW]) OR (”evidence” [TW] and ”based” [TW] and ”medicine” [TW]) AND ”limitations” [MH] OR ”criticisms” [MH] OR ”limitations” [TW] OR ”criticisms” [TW]. The titles and abstracts of the 95 articles identified (and the full text of the 47 felt to be potentially relevant) were reviewed by both of us for potential criticisms. Discrepancies (3 cases) were resolved by consensus. The reference lists of the retrieved articles were searched and experts in the field contacted in order to identify other relevant articles.
Criticisms expressed more than once (i.e., in 1 or more articles or at 1 or more seminars) were identified by content or qualitative analysis and included in this paper. The classification of criticisms was developed by both of us after a review of the criticisms that had been identified, with input from several members of the Evidence-Based Medicine Working Group (see Acknowledgements).
Our classification of the commonly cited limitations of evidence-based medicine appears in Table 2 . The first 3 limitations outlined here are not unique to evidence-based medicine but are universally encountered in the practice of medicine.
Shortage of coherent, consistent scientific evidence
Clinicians frequently encounter situations in which there is no relevant evidence from either basic or applied research. 11 The exponential growth in clinical research, coupled with international efforts to identify, sort and rationalize this evidence systematically, will eventually close many of these gaps. However, until that time, clinical experience and reasoning (based on principles derived from basic scientific research) ”must be applied to traverse the many grey zones of practice.” 11
Even when evidence exists, difficulties arise when it is inconclusive, inconsistent with previous studies, irrelevant to clinical realities or of poor quality. 12 Indeed, in few research studies are the results reported in the context of the totality of available evidence. 13 Although systematic reviews are a potential solution to this problem, inadequate attention to their methodology may lead to surprising variation in results and recommendations. 14 Thus, steps must be taken to improve and standardize the methodology and reporting of systematic reviews. 15 , 16
In our view, these problems, far from constituting a limitation of evidence-based medicine, highlight the importance of training clinicians to appraise research critically, to recognize the indeterminacy represented by confidence intervals and to apply the evidence, taking into account their patients‚ unique risks and values.
Difficulties in applying evidence to the care of individual patients
The universal occurrence of biological variation hampers attempts to extrapolate evidence, whether from basic or applied research, to individual patients. Thus, we disagree with the criticism that this problem is unique to evidence-based medicine. 17
To address this concern, researchers increasingly use particular study architectures (such as ”N-of-1” and large, simple trials) and carry out judicious subgroup analyses that are intended to improve our ability to extrapolate research results to individual patients in the ”real world.” 18 , 19 , 20 Furthermore, novel formats that enable clinicians to describe evidence to each other and to individual patients have been developed. For example, the number needed to treat and the number needed to harm have gained acceptance as useful means to make the evidence relevant to the individual patient. 21 , 22 Patient values can be incorporated into these expressions by means of formal decision analysis or bedside simplifications such as the likelihood of being helped or harmed. 23
Barriers to the practice of high-quality medicine
The gap between the demand for health care and the resources available to meet that demand is growing and results in clinicians having to care for more patients in less time. 24 This pressure impairs the ability of clinicians to apply any evidence, whether from basic or applied science, to their patients.
Per capita health expenditures have more than doubled over the past 2 decades, and over one-third of this rise is owing to the increased intensity of services. 25 Thus, it is not surprising that purchasers have increasingly attempted to control escalating health care costs by setting priorities and rationing services (explicitly as in the case of efficacious but expensive drugs like sildenafil in the United Kingdom 26 or implicitly as in proposals to provide antihypertensive drugs only to patients deemed to be at high risk 27 ).
Some have criticized evidence-based medicine for this curtailing of clinical freedom. 28 However, this process was well underway before the elucidation of evidence-based medicine. Indeed, increased attention to the principles of evidence-based medicine among policy-makers and purchasers should lead to the preservation of funding for proven efficacious therapies and the elimination only of interventions that have been shown to be harmful or ineffective.
The need to develop new skills
Unquestionably the practice of evidence-based medicine requires the acquisition and development of new skills (in literature searching and critical appraisal). Their mastery and application are formidable tasks and should not be underestimated. However, the assertion of some critics that clinicians are not interested in learning such skills is contradicted by surveys of practising clinicians. 5 , 6 , 7 , 8 , 9 , 10
Evidence-based medicine skills can be acquired at any stage in clinical training. Incorporating their acquisition into the routine of grand rounds, postgraduate and undergraduate seminars, and ”morning report” integrates them with the other skills being developed in these settings. 29 Members of clinical teams at various stages of training can collaborate by sharing the searching and appraising tasks. The different skills required for practising in the ”using” and ”doing” modes can be learned in sequence, thus avoiding learner overload. Indeed, for many clinicians the most appropriate means to achieving evidence-based practice may be through the ”using” mode outlined earlier in this article.
Limited time and resources
Critics of evidence-based medicine have correctly pointed out that its practice may require time and resources unavailable to the busy clinician. 30
Important developments to help overcome this barrier include the systematic reviews generated by the Cochrane Collaboration, the growing numbers of evidence-based journals (such as ACP Journal Club ) containing abstracts of quality- and relevance-filtered studies, and the creation of "best evidence" sections in a number of established journals. Moreover, electronic searching is increasingly being made available at the point of care, cutting time of access to the evidence to a few seconds. 31 The generation of databases of critically appraised topics (1-page summaries of evidence relevant to common clinical questions), 32 which can be quickly accessed at the point of care, 31 represent another time- and energy-saving solution for busy clinicians, as is the division of labour between members of the clinical team noted previously. Finally, although we can generate several questions for each patient we see (and become paralyzed by trying to address them all), we can pare them down to just one by balancing the question that would be most important to our patient‚s well-being against that which may be answered most easily, that which is most interesting to us and that which is most likely to be raised by subsequent patients. 4
Paucity of evidence that evidence-based medicine ”works”
Although agreeing that evidence-based medicine makes good sense in theory, its critics have quite appropriately demanded evidence for whether it improves patient out-comes. 33
No such evidence is available from randomized trials because no investigative team has yet overcome the problems of sample size, contamination and blinding that such a trial raises. Moreover, it is questionable whether withholding access to evidence from the control arm in such a trial would be ethical. However, outcomes researchers consistently document that patients who receive proven efficacious therapies have better outcomes than those who do not. 34 , 35 , 36
Given this evidence, the focus has shifted from whether to teach evidence-based medicine to how to do so, and recent randomized trials have compared alternative strategies for enhancing evidence-based practice. These trials have both discredited traditional approaches such as didactic lectures and validated newer approaches such as academic detailing (one-on-one educational sessions with a content expert) and seeking advice from local opinion leaders. 37
Many criticisms of evidence-based medicine stem from misperceptions or misrepresentations and may be answered by careful consideration of the definition of evidence-based medicine and the 5 steps outlined in Table 1 . 4 We include these misperceptions in Table 2 in order to clarify that they represent only pseudolimitations of evidence-based medicine.
For example, criticisms that evidence-based medicine denigrates clinical expertise, 17 , 38 ignores patients‚ values 39 or promotes ”cookbook medicine” 38 , 40 arise because of a failure to appreciate step 4 in Table 1 . 41 Moreover, because evidence-based medicine is cost-indifferent and directed toward maximizing the quality of life of individual patients, it may (and often does) result in policies that will increase, rather than decrease, costs (consider the provision of statin drugs for normocholesterolemic patients following myocardial infarction). 42 , 43 The most commonly cited pseudolimitation is that evidence-based medicine is an ivory-tower concept; 44 however, surveys and audits of front-line clinicians clearly refute this claim. 5 , 6 , 7 , 8 , 9 , 10 , 45 , 46 , 47 , 48 , 49 , 50 Furthermore, a common misperception is that evidence-based medicine is limited to doing, as opposed to using, clinical research. 17 Although a minority of practitioners of evidence-based medicine also do research, its practice is a method for providing care for patients, not a method for performing research.
The final misperception is that only randomized trials or systematic reviews constitute the "evidence" in evidence-based medicine. 44 , 51 Even the most vehement protagonist of evidence-based medicine would acknowledge that several sources of evidence may inform clinical decision-making. However, the practice of evidence-based medicine stresses finding the best available evidence to answer a question, and hierarchies of evidence have been developed to help describe the quality of evidence that may be found to answer various questions. Thus, randomized clinical trials are usually considered the ”gold standard” for establishing the effects of an intervention, but they are not the best sources for answering questions about diagnosis, prognosis or harm. Although this hierarchy has been criticized for devaluing the basic sciences, 51 we would submit that numerous studies over the past 4 decades have demonstrated the potential fallibility of extrapolating directly from the bench to the bedside, without the intervening step of proving the assumptions to be valid in human subjects. 52 , 53 , 54
Evidence-based medicine, like other models of care, 55 has limitations, and further innovation and study are required to resolve the issues raised in this paper. In particular, efforts need to be directed toward improving clinicians‚ access to evidence at the point of care; developing better methods of describing evidence to patients in order to facilitate shared decision-making; and conducting studies to test whether and how evidence-based medicine affects processes of care and patient outcomes.
This article has been peer reviewed.
Acknowledgements : We thank Drs. David Sackett, Ian Chalmers, Scott Richardson, William Rosenberg, Brian Haynes and Gordon H. Guyatt for their helpful comments on earlier versions of this manuscript.
Financial support was received from the Alberta Heritage Foundation for Medical Research, Edmonton, Alta.
Correspondence to : Dr. F. McAlister, Division of General Internal Medicine, 2E3.24 WMC, University of Alberta Hospital, 8440 112 St., Edmonton AB T6G 2R7; fax 780 407-2680; [email protected]
Essay on evidence based medicine (ebm) | patients | clinical psychology.
In this essay we will discuss about:- 1. Definition of EBM 2. Why EBM is Needed ? 3. Steps.
Essay # 1. Definition of Evidence Based Medicine (EBM):
One of the commonest definitions is as follows:
“EBM is the conscientious, explicit and judicious use of current best evidence in making the best decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”
The clinical expertise means the treating physician’s medical knowledge, experience and clinical skills accumulated over years of practice. It also means understanding the uniqueness of each individual patient as well as knowing the risks and benefits of adopting a specific therapeutic strategy for him.
This involves taking into consideration the values and expectations of each patient in addition to selection of the therapeutic agent most suited for him.
The values encompass the patient’s concerns, demands and preferences of treatment. The evidence comes from the published research materials, but their goodness and applicability are a function of their clinical relevance and sound research methodology as judged statistically. New strategies may invalidate and replace older ones when evidence indicates that the new strategies are safer, more precise and more efficacious.
Three other definitions of EBM are the following:
(1) “An approach to health care practice in which the clinician is aware of the evidence in support of his or her clinical practice, and the strength of that evidence”.
(2) “Integration of best research evidence with clinical expertise and patient values”;
(3) “The new paradigm deemphasising intuition, unsystematic clinical experience, and pathophysiological rationale as sufficient grounds for clinical decision making and stressing the examination of evidence from clinical research”.
Thus evidence based medicine is a medical approach which blends sound clinical judgement, the patient’s expectations and the best available evidence with reference to a therapeutic strategy. However in psychiatry its most important use today is in selecting therapeutic strategies.
It differs from the most commonly adopted traditional “replicating” model in that it does not seek or accept “blindly” strategies which have been “dictated” or “recommended” by “authorities”, including “standard textbooks” and “expert opinions”, without critical evaluation.
Apart from being a patient care model, evidence based medicine is also a “lifelong learning model”.
Essay # 2. Why EBM is Needed?
There are several reasons why an evidence based learning approach is necessary.
a. Information Needs:
All physicians have considerable needs for valid information with respect to their patient, centred on their diagnosis, treatment including prevention and the final outcome. Many of the information needs are often unrecognised or not met.
b. Inadequacy of Usual Ssources of Information:
The usual sources of information include textbooks, other medical literature (journals, etc.), expert opinions and didactic lectures. Of these, textbooks are often outdated and inaccessible, medical literature (review articles, information provided by medical firms, etc.) is often subjectively biased and varied, in addition to its being too voluminous; expert opinions are again “Opinions only” and not necessarily critically evaluated and didactic lectures are most often ineffective and impractical.
c. Lack of Information and Lack of Time:
The lack of information about the available resources and a lack of time may also contribute in making the needed information inaccessible.
d. Information Eexplosion:
There is an overwhelming explosion of medical data and their dissemination over the years. It becomes necessary to restrict search to a smaller field and to modify scanning methods so as to avail the needed information after ensuing soundness of methodology and validity of results.
e. Idiosyncratic Practice Modes:
An indirect effect of the information explosion is that individual practitioners unable to differentiate valid data from the rest, resort to varied and often idiosyncratic modes of clinical practice guided solely by self-assumptions that their decisions are the best clinical decisions. In reality, however they may not be the best decisions in the absence of any supporting evidence to validate the assumption.
Essay # 3. Steps in the EBM Process:
Practice of EBM involves five successive steps:
They are following:
1. Formulation of a well-defined answerable question regarding the patient’s clinical condition.
2. Tracking down the available resources and searching them for information pertaining to a particular question.
3. Critical evaluation of the evidence for its validity and clinical applicability.
4. Making a decision and integrating it with the clinical expertise to manage the patient.
5. Evaluation of the performance.
As for any new approach in medicine EBM also has its own critics and supporters. The critics hold that the message of EBM is not new and had been followed in medical practice all along. Some point out that there is no real proof for EBM’s effectiveness over the traditional approaches.
EBM takes away clinical freedom and all credit is given to evidence rather than to clinical judgement. EBM resorts to application of population studies direct to individuals without considering their uniqueness of personality and circumstances.
On the other hand supporters of EBM claim that clinical decisions are based on stronger evidence obtained through sound methodology. They point out that traditionally less than 5% of clinical decisions are evidence based.
Many are made on strong consensus among physicians. But half of all clinical decisions are based neither on evidence nor on consensus. Individual values and expectations and their uniqueness are given due consideration which they say is an important step in EBM.
When randomised control studies are lacking, the clinician is free to choose other kinds of evidence next in the hierarchy scale. Traditional medical skills are not downplayed but instead they are supported and strengthened by EBM. EBM closes the gap between research and practice, optimises clinical decisions and allows the practitioners to justify their decisions. According to them it makes clinical practice easier, safer and more effective.
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Clinical Psychology , Essay , Evidence Based Medicine (EBM) , Research Methodology
Evidence-Based Medicine Analysis and Policies
Evidence-based medicine is the use of systematically reviewed cases to make the best decisions concerning the health of a patient. It involves integrating personal expertise with available best clinical evidence from systematic research in treatment. This practice aims at improving the quality of healthcare and reducing the gap between research or information known and real-life situations. In addition, it reduces variations in interventions. The best evidence-based practice integrates patients’ values and circumstances, clinical expertise, and research evidence. This paper analyzes evidence-based medicine and the policies governing it.
The Process of Evidence-Based Medicine Analysis
The process of evidence-based analysis involves five major steps. The first step involves formulating of question to be used in finding relevant research. The second step is gathering –new practical knowledge needed is identified in this period. The third phase is appraising articles to ascertain their clinical usefulness and validity. The fourth is summarizing the evidence by tabling the results of evidence applications in a clinic. Lastly, the evidence is graded by evaluating clinical performance, and a conclusion statement is developed in the analysis final part.
The Major Players and their Roles in Evidence-Based Medicine Policy
The major key players in the Evidence-Based Medicine (EBM) policy are the government, hospitals, patients, and researchers. The hospital’s critical role is to guide patients and provide quality health care based on EBM. Researchers play a significant role in generating new ideas that solve medical issues and challenges. They are also required to improve the health of the population as well as the cost of care. The mandate of the government is to aid in strengthening and planning quality care. It also ensures health care facilities conform to the rules and policies guiding them. Patients are major EBM players because they have to cooperate with medics to achieve maximum benefits from evidence concerning their illness.
The Evidence-Based Levels
The levels of evidence are hierarchical, and they are classified according to their methodological designs and credibility in clinical practice. The first level is systemic review; it involves meta-analysis of relevant evidence from randomized controlled trials. Level two evidence is based on a systemic review of homogeneous cohort studies (Shah et al., 2019). Level three evidence is the results obtained from the systemic review of case-control studies. The fourth level of evidence is derived from case series, case-control studies, and low-quality cohort studies. Level five evidence is based on opinions of health experts, which are not based on mechanistic studies or systemic review results.
The hierarchy of evidence levels is also represented by a pyramid. The bottom part denotes findings from animal research and lab testing. The middle segments are evidence from case-control trials that summarize the treatment of patients without correlation. It is followed by randomized controlled trials, which are experiment designs conducted to reduce bias. Thereafter, the systematic review part of the pyramid follows, which connotes the assessment of high-evidence articles in evidence-based medicine. The highest level is meta-analysis where statistical and quantitative analyses of various randomized controlled trials are critically compared.
Review of the Case Constraints on Evidence-Based Medicine
Evidence-based medicine was emphasized and expanded by the Affordable Care Act (ACA) in the 2009 stimulus rule. It was then established by the Patient-Centered Outcomes Research Institute (PCORI) within the Centers for Medicare & Medicaid Services. However, this legislation restricted the use of the institute’s research in the Department of Health and Human Services (Cairney & Oliver, 2017). Federal lawmakers were concerned about controversies that may arise from the research findings in Medicare Advisory Payment Commission. For this reason, they placed constraints on how ACA can utilize evidence-based medicine.
Medicare currently covers the cost of care deemed necessary and reasonable. It does not consider evidence on the charges and effectiveness of treatment relative to others. In addition, Medicare does not compare effectiveness information when determining payment rates for services (Shah et al., 2016). This is because it links the cost of medication to reimbursement. In other countries, comparative effectiveness research is utilized in regulatory stages such as the approval of procedures and new drugs. However, the US restrictions on the use of comparative effectiveness research have been affected. One of the limitations is that secretaries can only use results from research conducted through a transparent and iterative process when approving Medicaid cover (Cairney & Oliver, 2017). In addition, it requires that the evidence gathering procedure should include opinions from the public.
The second restriction is based on the payment for services in Medicaid. Secretaries have been prohibited from approving claims which are solely centered on comparative clinical effectiveness research. The third constraint specifies that evidence from comparative clinical effectiveness research should not be used to determine reimbursement, coverage, or incentive under the title XVIII act (Tolan, 2019). This implies that a life of a terminally ill old person should not be prolonged at the expense of a young person who has no comorbid disorders. Lastly, the law restricts the use of comparative clinical effectiveness research in discouraging patients from choosing a treatment based on their values.
Case Constraint Analysis on Evidenced-Based Medicine
The constraints state that “The Secretary may only use evidence and findings from research conducted under section 1181 to determine coverage” (McLaughlin & McLaughlin, 2014, p. ). This shows that top-level evidence is used to justify the practice. In this case, evidence from the meta-analysis of systematic studies is appropriate. The constraint stating that “The Secretary shall not use evidence or findings from comparative clinical effectiveness research conducted” is supported by controlled trials (McLaughlin & McLaughlin, 2014, p. ). Thus, it belongs to the middle level of the evidence pyramid where case-control experiments are utilized.
Summary of the Policy of Evidenced-Based Medicine
The idea of evidence-based medicine is based on reliable and solid gathered evidence that improves health care delivery. Scientific methods are utilized in collecting information to prove facts. Although the outcome of evidence-based medicine is commendable, the government rarely makes decisions based on this. For instance, limitations have been placed on the use of comparative effectiveness research by lawmakers in the United States. It has been observed that the improvement of medical practice is hindered by politicians. This is because they make laws according to their political ideology rather than evidence. Thus, policy decisions concerning health should be made in the presence of some healthcare providers and patients’ advocates.
Evidence-based medicine is a transparent process that informs decision-making procedures in the health care sector. Clinical decisions are no longer founded on lessons from medical schools and the experiences of patients. This is because the results of rigorous clinical studies have been incorporated in determining treatment plans for each patient. Adopting evidence-based medicine lowers the cost of treatment and improves the quality of care accorded to patients, and, therefore, it should be adopted in clinics.
Cairney, P., & Oliver, K. (2017). Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy? . Health Research Policy and Systems , 15 (1), 35.
McLaughlin, C. P., & McLaughlin, C. D. (2014). Health policy analysis (2 nd ed.). Jones & Bartlett Publishers.
Shah, S. I., Brumberg, H. L., & Bearer, C. F. (2016). Toward development of evidenced-based quality parameters: What gets counted and who gets paid? Pediatric Research , 80 (2), 170.
Shah, S., Brumberg, H. L., Kuo, A., Balasubramaniam, V., Wong, S., & Opipari, V. (2019). Academic advocacy and promotion: How to climb a ladder not yet built. The Journal of Pediatrics , 213 , 4-7.
Tolan, P. H. (2019). Scaling up evidence-based interventions within the US public health market. Prevention Science , 20 (8), 1169-1172.
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Evidence-Based Practice in Medicine Essay
In a medical environment, the continued promotion of excellence and improvement is a necessity. As a field that directly deals with human wellness, its professionals are both personally and occupationally invested in promoting the best outcomes for their subjects; with the development in medical research and the constant introduction of new treatment methods, techniques and approaches, the state of healthcare as a profession changes rapidly. In the flow of new information, the use of the evidence-based practice, or EBP, becomes crucial. The ultimate goal of EBP is to ensure that both nurses and doctors are able to help their patients more effectively. By utilizing new data, better ways of promoting public health and wellness can be surmised. Furthermore, less effective or potentially harmful practices can be recognized on a structural level, leading to more positive outcomes for patients.
Medical researchers publish articles in specialized journals, which are then used to guide existing medical practitioners and move the field forward as a whole. Healthcare organizations use a variety of practices to promote better adherence to EBP, centered on cultivating the correct culture within their organizations and training staff. Research has shown that leaders also play a big role in the process, promoting the right attitudes and establishing an EBP-based work environment (Allen et al., 2018). In addition, specialized professionals and training can be used to help healthcare organizations implement evidence-based practice. Investigations into the current competencies of medical professionals alarmingly show that many are unable to implement principles of EBP into their work or lack sufficient knowledge about its importance (Melnyk et al., 2017). For many nurses and doctors, the skills to properly utilize medical data in their work are not present, which is a problem for the profession as a whole.
Allen, P., Jacob, R. R., Lakshman, M., Best, L. A., Bass, K., & Brownson, R. C. (2018). Lessons learned in promoting evidence-based public health: Perspectives from managers in State Public Health Departments. Journal of Community Health , 43 (5), 856–863. Web.
Melnyk, B. M., Gallagher-Ford, L., Zellefrow, C., Tucker, S., Thomas, B., Sinnott, L. T., & Tan, A. (2017). The first U.S. study on nurses’ evidence-based practice competencies indicates major deficits that threaten healthcare quality, safety, and patient outcomes . Worldviews on Evidence-Based Nursing , 15 (1), 16–25. Web.
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