Evidence-Based Practice: how journal articles become standards for patient care
Evidence based medicine practice
EVERY person in healthcare knows what evidence based practice (abbreviated as EBP) is. It is a set of subscribed “gold standards of care” that must be followed in the treatment of a patient. For example, if you come in for a rapid strep test and that test is positive for strep, the EBP is to give you a penicillin based antibiotic, and if allergic to that class of meds we give you a macrolide antibiotic such as azithromycin. If you come into the ER with chest pain, EBP states that EKG and labs are done STAT, and if your EKG comes back as an ST elevation heart attack, or a STEMI, you MUST be in the cath lab within 60 minutes to get the blockage fixed. Evidence based practice dictates everything. Your treatment, what insurance will pay for, and EBP is designed to make every medical facility treat all patients the same way for the same condition. Evidence based practice is also what keeps healthcare providers from being sued. If you are following EBP and gold standards of treatment, your risk of litigation goes down tremendously. If you follow EBP, you did not fail to meet the “required treatment” need of the patient. So, even if the patient outcome was not ideal, so long as you adhered to EBP, you did your job. More often than not, if a patients healthcare situation takes a sudden unexpected nosedive very quickly, there was a failure to adhere to a practice standard. A CT or MRI wasn’t done. Labs were not checked. Dosage of a medication was wrong. Allergy list not reviewed. Things like that. What I have tried to figure out for years though is does EBP help or hinder patient care? Are we so wrapped up in checking the boxes that we did not listen to a patient? What if that EBP gold standard was NOT the best fit for the patient? We can stand there and say “well I followed all the guidelines but they still died”. That does happen. Organically and despite all efforts. Despite what we do, people will still die. We are all mortal and we cannot save everyone in a medical crisis. But do we update the EBP guidelines often enough? Do we actively research these and make adjustments and pivot as needed? And again, who makes the EBP guidelines? Is there some “Board of EBP” that says “oh yes, we are gonna make this the standard now”? Well, that is a complicated question. The answer is “it depends on who paid for the study that became EBP”.
This interesting article came out a few weeks ago. https://www.bmj.com/content/bmj/376/bmj.o702.full.pdf
This article supports that yes, EBP was a shift towards the science. Making sure we adhered to the scientific standards of healthcare. Tested and proven models of care. But the core question many in healthcare have is this: WHO decides WHAT is EBP? Are these “golden rules” decided by a large group of people? Or by a small core of people that we are not even aware of their names? Philosopher Karl Popper wrote “A science of real integrity is when practitioners do not cling tightly to hypothesis and protect the stringent science”. But again, WHO decides the SCIENCE? In the fall of 2021, Dr. Anthony Fauci determined that he, himself, was “science”. A former attending physician I worked with proclaimed himself as the “science” when he followed his regimented protocol for treatment of sepsis patients. Fluids fluids fluids. Even if the patient had renal disease and couldn’t eliminate those liters of fluids; or, they became so fluid overloaded it exacerbated their congestive heart failure. His protocol was SCIENCE! I remember a spicy young medical fellow questioning that sepsis protocol and that poor young doctor was bad mouthed, dressed down, and mocked for the mere suggestion of an alternative to the sepsis protocol. How DARE he speak out to that decades long in practice attending physician! What we should have looked at is wow, here is a fresh out of med school and residency doctor, in his 2nd year of fellowship, and *maybe* he learned a few updated things in his training? That might lead to better outcomes for the patient? That one size does NOT fit ALL? But does that now discredit EBP? Does EBP really follow the science?
The reality is, healthcare is dictated by the pharmaceutical industry. Let me break this down: the pharmaceutical industry pays for all clinical trials of a medication or treatment. THEY own the data and results. THEY cherry pick what data comes out and what does not. THEY have ownership to their shareholders to make a profit. THEY will determine a treatment or practice standard EVEN IF it is not best for the patient. Then it trickles down hill. Raw data is hidden, adverse events are suppressed, and if the patient dies, well, healthcare can clean that part up but NOPE, it was NOT that medication we gave you! Pharma said it is SAFE!
The tangled web of pharma bring a drug to market goes even deeper. Drug companies outsource the clinical trials to other agencies. Those agencies are gag ordered on the data results. The data is given back to the drug company. And it has gone deeper. Universities are now getting in on the pharma research game. There is big money in big endowments and grant funding to get in on the pharma game. So prestigious universities who once flew the “PRO SCIENCE” flag has now been bought into the pharma web as well. With dwindling public and state financial support, their way to “stay afloat” was to sell out to the highest bidder: pharmaceuticals. They now pump out research, write journal articles from a position of “science expertise and authoritarians” when in reality, they are merely the middle man for pharma on what pharma wants reported. There is no autonomy of true science reporting going on by these universities! They are writing the narrative that pharma wants them to write with the writer’s fancy “PhD, MD, MPH” initials after it. And they cash the checks written to write the piece. So this leads down another path: how accurate ARE the prominent healthcare journals? The New England Journal of Medicine? The Lancet? The American Journal of Medicine? Nature? I suppose it depends on who wrote the piece. But if we look to these journals as the lighthouse beacons to 100% support and develop evidence based practice guidelines, HOW DO WE KNOW a truthful journal article from a false one? We don’t!
We have now taken universities and removed the relationships they have with fellow academics, and replaced them with “key opinion leaders” who focus on fundraising and attracting corporate sponsors. These key opinion leaders then attract corporate sponsors (drug companies). They use the prestige of their University’s good name (Yale, Harvard, Stanford, MIT, etc) and sell it to the highest bidder. And the highest bidder has that university do whatever dirty work they want done. THEN, on the flip side of this, if someone NOT funded by that university does a study that contradicts the paid narrative written by the university researchers, well, that opposing scientist is labeled as false, wrong, and THEIR journal writing is not published. EVEN IF IT IS TRUE. Because, well geez, WHO would believe an independent researcher of 30 years in the field over some AMAZING journal article written by Harvard!!!!!! We are seeing this unfold in real time right now.
Have you seen any well funded public universities do ANY studies about treatment of covid? The genetics of the covid virus? Anything? NOPE. Crickets are CHIRPING in these academic driven laboratories. Who IS talking about it? Independent researchers. Dr. McCullough raised a great point in December 2021, that if all the academic research masterminds got together early on, we would have discovered a plethora of treatment options for covid. Why are they all silent? Why was no information shared and studies done? Why was the only option “come to the ER if you cannot breathe”? That is not how academic medicine historically operated. It has been bought and paid for. They were paid to NOT do that kind of research.
How do we fix this deadly debacle we have gotten ourselves into? By bringing back independent research. We take pharma dollars OUT of the universities. We stop mixing private sector with the educational institutions as a pay for play research game. Independent drug trials with ALL clinical data shared. Because if the end goal is evidence based practice for patients, you must know all the data on the table.