Physicians are barraged with demands to implement evidence-based practices (EBP). Hesitate and you risk being labeled as part of the medical axis of evil. Some resisters may favor "superstition-based practice." Not me. But, I do believe that the evidence that evidence-based practice works in actual practice often isn't good enough.
Some EBP recommendations make good sense. Give depressed patients a full trial of antidepressant medication -- OK, I can do that. Others are difficult to impossible. How do I find a local practitioner of interpersonal psychotherapy? It may work, but hardly anyone does it. The same for many psychiatric EBP recommendations, such as frequently measuring BMI and lipids in schizophrenics.
Efficacy studies supporting such recommendations are often done in academic settings, then extended in real-world "effectiveness" trials. Unfortunately, much such work is shelved, or done halfheartedly. Often EBPs contain unfunded mandates -- great ideas requiring resources you don't have. Practitioners may be justified in skepticism.
Rather than more EBP, what we really need is what has been called PBE -- practice-based evidence. High-quality scientific evidence that is developed, refined, and implemented first in a variety of real-world settings.
Use real-world practices as laboratories for developing effective treatments.
Revive quality improvement as an academic discipline since QI projects are perfect models for PBE.
Develop modular treatments that can be incorporated into existing practices.
Use online technologies to the fullest -- for collecting effectiveness data; training providers; educating patients; and for testing, monitoring, and rewarding effectiveness.
Eventually we will have PBE -- practice-based evidence. I'll be first in line to apply it!
That's my opinion. I'm Dr. David Hellerstein, Associate Professor of Clinical Psychiatry at Columbia University in New York.
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Cite this: Practice-Based Evidence Rather Than Evidence-Based Practice in Psychiatry - Medscape - Jun 16, 2008.