David Sackett and the Meaning of Evidence-Based Practice
The new New York Times parenting section provides “evidence-based guidance for new and expecting parents.” Evidence-based books for parents examine parenting choices and attempt to offer a population and research-based approach that guides choices and eases parental anxieties. Evidence-based medicine is the beating heart of my nurse practitioner master’s program. As I see evidence-based-everything everywhere, I wonder how the idea of it as a practice and principle has changed from its inception. I was curious about where it started and my curiosity led me to Mr. Evidence-Based Medicine himself, David Sackett.
David Sackett, known as the father of evidence-based medicine, died in 2015. His push for evidence-based practice disrupted the conventional medical system where the common reasons for certain treatments were validated by authority and a “this is how it’s always been done” attitude that treated new practitioners like inept children who needed to learn the law of the land. He was known early on as a trouble maker who challenged the status quo and the way things were always done, and later, as an excellent communicator with a great sense of humor who knew how to bring good ideas to life with story, excitement and entertainment.
According to his obituary in The Lancet, Sackett believed “experts too often become detrimental to their field” and, later in his career, he focused on helping researchers develop their studies and protocols. He challenged people to think differently, employ skepticism, and question how the world works and his influence has trickled into almost every professional field. Evidence-based, the idea and application, started as a disruptive, threatening concept, but it has journeyed into the comforts of the mainstream, shaped and altered along its path and it has become a trend, a buzzword, a selling point in a world full of choice and the unknown.
“Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. ”
Those who criticize evidence-based medicine find fault in its generalization and a focus on averages over individuals. They believe it rests on reductionism and can impact patient-client relationships and clinical judgment. Additionally, as evidence-based everything gains popularity and visibility, others try to manipulate and misuse research to promote their own value or reputation. These flaws are not inherent to evidence-based practice, but they are inherent to our human nature. Sacketts belief that experts can harm their field reminds me of Wendell Berry’s essay, In Distrust of Movements. In it, he explains how movements fail to support their cause when they lapse “into self-righteousness and self-betrayal.”
Berry described how he was confused when people started to use the idea and movement of organic agriculture in giant monocultures, and how he was less surprised when the word organic came to include practices like genetic engineering and food irradiation. Words that are connected to meaningful ideas and behaviors can lose their power and purpose when they are adopted en masse for the purpose of selling or pretentiousness. He said, “The worst danger may be that a movement will lose its language either to its own confusion about meaning and practice, or to preemption by its enemies.”
While both Sackett and Berry recognized that language and words connect intimately and inextricably to individual people, practices and values, there is a loss of nuance and humanity when the words are over-simplified and ideas are repurposed to serve corporate incentives. John Ioannidis described this loss of the core essence and meaning of evidence-based medicine as a hijacking. As evidence-based medicine grew as a movement, it started to serve individuals less and those who benefit financially more. Ioannidis said,
Under market pressure, clinical medicine has been transformed to finance-based medicine. In many places, medicine and health care are wasting societal resources and becoming a threat to human well-being. Science denialism and quacks are also flourishing and leading more people astray in their life choices, including health. EBM still remains an unmet goal, worthy to be attained.
I study and write about evidence-based medicine, but I have to admit that when I see evidence-based guidance applied to everything, I feel a sense of wariness and loss of meaning. Part of this is the way I see people applying the idea of evidence and research. Evidence-based medicine does not have a singular meaning. It’s not just data, or journals or research. Sackett defined it as the “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Evidence-based practice is an incorporative exercise, not a blind doctrine and it is supportive rather than authoritative.
Sackett pushed for high-quality evidence because he wanted to avoid bias when he was treating his clients, but, as the editor of Spinal Cord, Lisa A Harvey, pointed out in 2017, “Sackett never argued that we should only be driven by estimates of population-based averages. To the contrary, he was a strong advocate of the importance of combining this information with clinicians’ and patients’ perspectives, experiences and priorities.”
In other words, Sackett was aware of nuance and the importance of the individual. When I observe language that feels ubiquitous and disembodied, it helps to track it back to the individual who initiated the idea and discover that they were led along their path not by their desire to seek power, money or influence, but by their desire to improve the daily experience for individuals. David Sackett didn’t believe in evidence-based medicine at the expense of perspective, experience and relationships, he believed in evidence-based medicine because he wanted to improve patient outcomes, experiences and relationships.
Next time you see evidence-based anything, remember your experience and perspective counts, as do those who came before you and the next person you talk to who does things differently than you. When Sackett was diagnosed with metastatic cholangiocarcinoma, he created a comprehensive interview document for the various institutions and individuals who wanted to talk to him about his life. In one of my favorite sections in this inimitable document, he attributed part of his success to “an insuppressible capacity for finding and injecting fun into everything I did (sometimes to the distress of others).”
I love the idea of Sackett, so interested in evidence and research, as a guy who was determined to not only improve medicine, but to enjoy the process of learning and discovery. As evidence-based guidance as a movement becomes more serious and commercial, it is remarkably instructive to remember the man who was guided by deep caring, humor and appreciation for the support and guidance of others.