‘Evidence Based Practice’ is only as good as the systems in which it is created, and the people by whom it is used
Ever heard of the term ‘evidenced based’? Or ‘Scientifically proven’?
Perhaps you’ve come across the NICE guidelines, which aim to review and summarise the evidence for particular procedures, interventions, treatment and therapies’ to conclude best practice within a given area relating to healthcare.
Sounds like a good idea right? To look at what we know and base our medical or health decisions on that. And in theory it is a good idea. However, in practice it is only as good as the people and systems by which it is created, analysed and used. And because our systems (which are made up of people) are biased; ‘evidence based practice’, in practice, has shortcomings that are often over-looked. Here I outline some of my thoughts about the potential short-comings:
The available evidence base is not always followed or communicated to patients accurately. These are some examples:
The dangers of sodium valproate in pregnancy was documented from the 1980s with more and more research supporting this finding, and yet it is still widely prescribed, particularly in Psychiatric settings (Rakitin, 2020)
Despite evidence of the racism within healthcare systems (e.g. black women 5x more likely to die during childbirth (MBRRACE, 2018) and black people are 4 times more likely to be detained under the mental health act (gov.uk, 2021), the government found ‘no evidence’ of systemic racism in their Commission on Race and Ethnic Disparities: The Report (2021), which was later condemned by the UN (2021).
Studies often under-represent marginalised groups. Despite this, research is deemed to be applicable to them - this is the case for current proposed NICE guidelines on induction, which proposes that clinicians ‘Consider induction of labour from 39+0 weeks in women with otherwise uncomplicated singleton pregnancies who are at a higher risk of complications associated with continued pregnancy (for example, BMI 30 or above, age 35 years or above, with a black, Asian or minority 24 ethnic family background, or after assisted conception)’ - despite no research surrounding race and induction and outcomes (NICE, 2021). Similarly to the point above re: The Commission or Race’ report, this type of conclusion shifts the focus onto black bodies and away from the systemic racism within the system.
People who are pregnant, planning to become pregnant, breastfeeding or who have gone through the menopause are often excluded from studies. Its as if, only the seemingly static (cis/het) male body is ‘normal’ and therefore worthy of research/that findings can be ‘accurate’. Anything deviating from this the cis/het male is abnormal. A classic example of this is when breastfeeding and pregnant people were excluded from trials into the Covid vaccine, leaving no trial information for pregnant people to base their decisions on.
Summaries of the evidence base in the form of guidelines can be interpreted by healthcare systems as rigid ‘rules’ or ‘policies’ - as such these ‘policies’ are used to assert dominance, coerce and control, again particularly over those most marginalised. An example of this is maternity services ‘policies’ not ‘allowing’ women to be admitted unless they have an internal examination to check how dilated they are, or being told they are not ‘allowed’ to have a home birth if they fall into certain risk categories.
Professors across the UK are 72% male; 82% white; and 97% non-disabled (HESA, 2019/2020). These professors often drive research in their given area of interest and specialism, feeding into national priorities for what should be researched - it is this research that forms some our evidence base. Obtaining large scale funding outside of the University/healthcare system is very difficult.
Indigenous wisdom, feminine wisdom, or any dissenting voice, particularly from marginalised groups will often be ignored or receive the rebuttal that there is ‘no evidence base’ - a power play designed to silence and undermine, that is, until it is found to be efficacious by western science - my own learning on this has come from the Anti-Oppression Educator, Ravideep Kaur and the Clinical Psychologist and Founder of The Brown Therapist Network, Dr Tina Mistry.
Finally, ‘Evidence based medicine’ is often, wrongly, reduced down to what the ‘gold standard’ Randomised Controlled Trials find - but this is not how evidence based practice was intended to work. The evidence base was designed to democratise power and knowledge (Maier, 2012; ) and should include:
the best external evidence
individual clinical expertise
and patient choice
However, in light of the points made above, this definition is problematic. Although designed to democratise power and knowledge - if the evidence is conceived and produced in a system of bias and if the individual with clinical expertise is unaware or unable to acknowledge their own bias, or simply unwilling to utilise any evidence that contradicts their ‘way or working’, then the idea of utilising ‘the evidence base’ becomes entirely problematic. As such, the evidence base is only as good as the systems and the people who conceive, develop, fund, conduct, analyse, interpret, and use the research.
In order for evidence based practice to become more useful, clinicians have to be not only aware of the available evidence, but be able to critically examine it (who conducted it? who funded it? how is it biased? what does it not tell us?) AND we have to be able to examine, acknowledge and own our own biases as clinicians, researchers, funders, panel members etc., with the aim of dismantling the systems that give disproportionate power to some and cause harm to those most marginalised.
So, the idea of using ‘evidence based practice’ is a nice one, but will only work once we are able to acknowledge and dismantle the systems of oppression that are inherent within the entirety of the research process…and with even our own government dismissing their is a problem, we have a long way to go.
