Trisha Greenhalgh’s book reminded me of that well-known adage: “Give a man a fish, you have fed him for today. Teach a man to fish and you have fed him for a lifetime.” The proverb speaks to the value of empowering people with skills and knowledge that last beyond their immediate context or use.

Greenhalgh hopes to help front-line practitioners to do four things. First, to formulate problems into answerable questions. Second, to find the right evidence to answer those questions. Third, to appraise critically that evidence. And, finally, to use the evidence to alter their behaviour and that of others’ around them.

The book may be directed at medical clinicians but these skills apply equally to children’s services’ practitioners, social workers, youth justice workers and psychologists. Each of them has something in common: they have seen the evidence-based practice movement become a central theme in professional rhetoric. Many are dubious, largely because they have been fed evidence-based practice as a set of guidelines or protocols that apparently undermine clinical or professional judgment.

The likes of Britain’s National Institute for Clinical Excellence and the Social Care Institute for Excellence provide literally thousands of pages of guidance for practitioners summarizing the latest research findings or directing practitioners to follow particular methods for responding to a particular problem.

But this is not evidence-based practice. These examples ask practitioners to consume and digest information that someone else has searched for, appraised and summarized. There is certainly merit in this function and this form of guidance shouldn’t cease. But it is the proverbial fish; Greenhalgh’s endeavor is to teach practitioners to fish for themselves.

So, let’s review the steps to becoming an angler for evidence. First, formulate the problem at hand. This means turning the problem into a set of answerable questions. Be clear about for whom the problem is relevant, which kind of intervention(s) you might consider, and the desired outcomes that are sought.

Next, track down the best evidence available to address those questions. Remember, only 10-15 per cent of the literature available is likely to have any scientific longevity. Indeed, much of the published literature has flaws that limit the general applicability of the findings, or the confidence that can be placed in the conclusions, to a wider context. Two skills become important in that context: first, efficient methods for searching the literature base and, second, the ability to appraise critically papers to sort the wheat from the chaff.

Much of Greenhalgh’s book is devoted to imparting both of these sets of skills to readers. Some of her directions feel counter-intuitive to someone new to this game. For example, “if you are going to trash a paper, you should do so before you even look at the results”. Bad science is bad science. It does not matter if the authors find a statistically significant association; if the study design is inappropriate then results cannot be relied upon.

If the challenge of getting more evidence-based practice to occur rested only in educating professionals to become competent in these skills, we would be home and dry. But this approach does not lead to sustained behaviour change in practice. Advocates suggest instead that instruction needs to happen where the rubber meets the road: at the patient’s bedside, in the clinic or in the home.

Moreover, there is work to be done to change organizations and the culture of practice generally. Supporting and empowering practitioners to consult evidence as part of their day-to-day work means providing access to the literature and time to consult it. Standards must be set for the quality of evidence that is circulated and training given to ensure practitioners know how best to use the information in their decision-making.

Reference:
Greenhalgh, T., (2006) How to Read a Paper: The basics of evidence-based medicine, Blackwell Publishing, 3rd edition.