Synthesize evidence and they will change?

Evidence-based medicine (EBM) is an outgrowth of the 20th century Western world's embrace of modernity based on the belief that by compiling, categorizing, synthesizing, and grading the medical literature the wisdom accumulated in the synthesis would move medical practice away from its anecdotal and traditional roots into a golden age of rationalism. Clinicians guided by evidence reports, metaanalyses, and quality grades would experience the benefits of the enlightenment and embrace the progress and improvement inherent in modernity. Implicit in this sequence is an untested assumption (quality grade of “poor,” recommendation = I) that physicians would desire to modernize their practice, and furthermore, inherent within the accumulation and cataloguing of evidence would be the motivation to change their behavior. This is analogous to the assumption in the movie, Field of Dreams, where the builder of a baseball stadium in the middle of a cornfield in rural Iowa repeatedly claims, “build it and they will come.”1 Berghella et al work within this paradigm and the untested assumptions of EBM and provide readers with an excellent summation of evidence-based intrapartum care.2 Despite the quality and thoroughness of their work, the question remains—is EBM effective at improving physicians' practice?

This hypothesis—compile and grade evidence and practice will subsequently change—has seldom been tested despite its adherents' firm reliance on hypothesis testing as the first step to rational practice in all other endeavors. Gülmezoglu et al3 took the brave step of scientifically evaluating that hypothesis using the premier tool available to EBM proponents: a randomized clinical trial. Using state-of-the-art design techniques with cluster randomization of hospitals, they conducted a rigorous trial that culminated in a negative result. Making practitioners aware of the quality and quantity of evidence about obstetric practice and giving them increased accessibility and training in EBM failed to change their behavior in any significant fashion. This builds on the negative results of other trialists modern enough to test EBMs embedded “build it and they will come” hypothesis.4

I learned how little effect EBM had on clinical practice early in my career. Standing on the better performed trials of European colleagues conducted on the routine use of mediolateral episiotomy in vaginal births, I conducted a small trial of midline episiotomy—routine vs limited—and found that midline episiotomy not only did not protect the rectum against severe injury as was the case with mediolateral episiotomy but also predisposed to severe injury.5 The evidence of harm was corroborated in multiple observational and experimental studies, and one could conclude in the early 1990s with all the confidence EBM allows that routine use of this procedure should be abandoned.6 Despite this evidence, the US practice did not change, and it remains to be seen what a government-sponsored evidence report published on this topic will accomplish,7 and if the valiant effort of Berghella et al to change intrapartum practice has an impact. Interestingly, Gülmezoglu et al3 showed the same failure of EBM to alter episiotomy practice in their trials, as this was 1 of the behaviors they hypothesized that an evidence-based practitioner would limit.

Thus, EBM is left with a gaping hole in its armor. There is no proof that evidence, no matter how clearly it is formulated and spoon-fed to clinicians, will change practice. Society would clearly benefit from better understanding what drives physicians' behavior and decision making. As any true modernist would agree, the entire range of possibilities must be explored. This would include economics, consumerism, public opinion, advertising, and medicolegal concerns to name just a few possibilities. This investigation into clinician behavior will require inputs from social scientists, and its qualitative aspects may actually be more important than the quantitative. One wonders if a dialogue with the pharmaceutical industry, which pays an army of representatives to visit clinicians with the goal of changing practice, might not be a good first place to start.

Our research team consisting of investigators at the Institute of Clinical Effectiveness and Health Policy in Argentina, Tulane School of Tropical Medicine and Hygiene, and the University of North Carolina recently reported a trial in which we tried to change clinicians' intrapartum practices by using “academic detailing.”8 This is patterned on behavioral change literature and consists of the selection and training of opinion leaders in each hospital, interactive workshops, one-on-one academic detailing visits, reminders, and feedback. In this cluster, randomized, controlled trial in hospitals in South American we were able to increase the use of prophylactic oxytocin in the third stage of labor and diminish the use of episiotomy (actions the Berghella review endorses). Moreover, this change in clinician behavior actually improved outcomes by reducing the occurrence of postpartum hemorrhage. The behavioral changes in labor and delivery practices were sustained for 1 year after the study.8

These results beg the question of whether we need more evidence reports, systematic reviews, or metaanalyses or if our patients would be better served by our taking the evidence we have accumulated and investing in interventions to change practice. Such an approach will require us to acknowledge the limitations of EBM and move from modernity to postmodernity. Postmodernity teaches us that not only are facts and evidence important, but that to change practice we must enter a dialogue. This seems to be the case even with physicians who have been exposed to the intensity of indoctrination into EBM inculcated by medical schools and residencies.

As I worked on this editorial I read the obituary of Edwina Froehlich. Ms Froehlich and 6 other nonprofessional women began the LaLeche League in a Chicago suburb in 1956 to promote lactation. Their motivation was not evidence based, although evidence would later support their work, but founded on the traditional concept of natural law. They used attraction rather than promotion and centered on a one-on-one relationship with clinicians and new mothers to promote breast feeding. This non-EBM approach in practice change was instrumental in raising breast feeding rates from less than 30% in the 1950s to more than 70% in the United States today.9 We as investigators and clinicians who produce and use medical evidence and who want to improve health outcomes would do well to ponder the route she took to change perinatal practice.