My Dominant Hemisphere

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Evidence Based Medicine in Developing Countries

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UPDATE 1: Check out multimedia from recent international meetings of the Cochrane Collaboration that have touched on this topic: here, here and here.

Have developing countries actually been active in EBM (Evidence Based Medicine)? This was a question that kept ringing in my head during a discussion I had with some of my buds recently. Speak to a Joe medic in any of the medical establishments in a country like India, and you can’t help feeling that developing countries for the most part have become consumers of research that cannot be applied to them. These medics are not only being taught but are also being tested on guidelines developed by a plethora of alien organizations such as NICE (National Institute of Clinical Excellence-UK), SIGNS (Scottish Intercollegiate Guidelines Network-UK), Cochrane (UK), ACP (American College of Physicians-US), CDC (Centers for Disease Control-US), NIH (National Institutes of Health-US) and many others in their curricula. Most of these guidelines have been produced for patient populations that are entirely foreign to them.

The only international body with a modicum of relevance to their lives and that of their patients and one which cuts across all geographical and cultural lines is the WHO (World Health Organization). Some might argue that such an enormous and overarching agency as the WHO is intrinsically incapable of producing practice guidelines that might be sufficiently context-centric to be of any use. The WHO sure has a lot of responsibility on its hands and it really is difficult to produce guidelines that apply to all geo-cultural contexts. Indeed, the WHO has produced only a handful of guidelines to date.

India and developing countries like it, desperately need indigenous agencies to construct and regulate guidelines that are appropriate to their peoples’ resources and needs. It is extremely common, for example, to see how guidelines by some agency are taken lightly solely because of resource constraints (transportation problems, lack of appropriate instruments, etc.). Actions that a clinician needs to make given these constraints, need to be backed by evidence. The whole idea of EBM is that actions need to be based on the ‘best available’ collective body of scientific evidence pertaining to a problem – pathological, economic, whatever. Doesn’t it make sense then, to look for ‘evidence’ backing a given course of action to our problems?

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We do have bodies like the ICMR (Indian Council of Medical Research) making progress, but honestly we aren’t doing enough. Over the course of my undergrad career, perhaps the only ICMR guidelines we came across were a handful of appendices at the back of a pediatrics textbook. I mean, come on! We can do better than that, right? The arguments linking this appalling void to decreased government funding are no doubt valid. Budgets allocated to healthcare are grossly below the minimum ‘5% of Gross Domestic Product’ standard set by the WHO and quite surprisingly have kept declining. Amidst this budget-strapping,  public healthcare establishments are overwhelmed by the demand for clinicians whose focus is on the manual delivery of healthcare services rather than research. In the ‘medical automobile’, these clinicians are just too busy being passengers in their back seats to care about driving. This unbalanced emphasis has had a profound impact on the very nature of our medical society. Its effects are visible right from the very beginning, as medical students enroll into institutes. Students are not even remotely exposed to the tenets underlying academic medicine and there is absolutely no mentorship mechanism in place at any level, all the way up to post-graduation and beyond. Departmental research is obscenely underfunded and students lack motivation to get involved in the absence of a nurturing environment. To make matters worse, owing to the abject lack of any academic medical component whatsoever in their curricula, students find it near impossible to take time out to engage in any form of academic activity at all. Even if they do manage it, their efforts often receive no curricular credit. Post-graduate students take the thesis requirement casually and often resort to a trial-and-error hodgepodge approach in the absence of necessary guidance. The situation finally spirals down to a vicious cycle where the blind lead the blind. End result: Institutes in chaos whose sole purpose is to produce en masse, semi-literate manual clinicians of low-innovative-potential who can’t even search or appraise medical literature, let alone use it properly.

Let’s just try to understand why this is the need of the hour. It not only paralyzes our education system but also our fragile economy. How does it degrade our economy? Well, without national guidelines there can’t be a just audit system in healthcare establishments. Without audits, resources are squandered and quality of care declines. When quality declines, the disease burden in a population rises and that in turn leads to an economic vicious cycle as national productivity declines.

How do we solve this?

  1. Government funding on healthcare ought to increase. Clearly, providing concessions and subsidies to private establishments hasn’t and most definitely isn’t going to produce results. Private establishments only care about making money – from the public or the government, and that’s all. Unless incentives are provided to them to engage in academic medicine or research, they aren’t going to bear the torch. In a developing country like India, the sheer demand for manual services forms a competing interest for these entities.
  2. Even if public funding is lacking, it might be possible to develop meaningful research. Some of the most groundbreaking research comes out of very small undertakings. It didn’t take a million dollars for us to realize the benefits of surgical asepsis.
  3. Hierarchical translational research bodies ought to be created – private or public or a possible mix of the two. Guidelines need to be produced and taught at medical schools. Students should no longer need to put up with the arbitrary whims of their superiors in the face of inapplicable guidelines in their textbooks.
  4. Audit systems should be enforced at all healthcare establishments. Students and practitioners should be taught how to audit their departments or practices.
  5. An academic component should be incorporated into the medical curriculum at all career grades – whether optional or otherwise. Mentorship mechanisms should be brought into place and could be incentive driven. Sources of funding and grants should be made more accessible and greater in number.

I hope readers have found this post interesting :-) . Do care to leave behind your comments.

Readability grades for this post:

Kincaid: 11.0
ARI: 12.2
Coleman-Liau: 14.7
Flesch Index: 49.1/100
Fog Index: 14.7
Lix: 50.3 = school year 9
SMOG-Grading: 13.0

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7 Responses

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  1. Assalam,

    The article you’ve written, for me, really brings into focus the haphazardly (un)oriented way medicos are left to deal with the undergraduate mbbs curriculum… there is a very fragile support system comprising a handful of senior undergrads/ house surgeons and a rare professor or two… There is no exposure to
    extra curricular academic activities and to compound this no one’s even interested!….I think the suggestions you mentioned at the end first need to implemented in our colleges and teaching hospitals…

    The article was a really interesting and informative read.

    Anonymous

    Anonymous

    April 29, 2008 at 4:55 pm

  2. Sarah – W’salam! Thank you for those wonderful thoughts.

    Do care to drop by again :-) .

    Firas MR

    April 29, 2008 at 5:56 pm

  3. Sarah – Now that you mentioned ‘house surgeons’, I think focusing on this dubious, nay downright dumb usage of the term ‘house surgeon’ by the establishment here, deserves serious thought. Students are uwittingly sucked into this vortex. Either unconsciously or as a means to pacify their inflated self-esteem. The entire free thinking world not to mention the ECFMG, classifies house surgeons from India as medical students, yet most house surgeons end up giving the lay public the impression that they are qualified doctors. Result, lacerated skulls, broken arms, etc. when something goes wrong. Most superiors too view them as past the medical student stage, take advantage of the confusion and make bold claims of fulfilling staff shortages when in fact the only ‘real’ staff at teaching hospitals comprise mainly of but a handful of people.

    Not only that, many proponents of compulsory rural service for house surgeons deceptively make use of this nonsense to push ahead their agendas, saying that the rural public will be taken care of by qualified doctors. Who are we kidding?!

    Your final year of medical school isn’t the 4th year. It’s the 5.5th year.

    I think terms like ‘intern’, ‘house surgeon’, etc. are so archaic and varied in their usage across the world, that they ought to be removed from our lingo altogether.

    Firas MR

    April 29, 2008 at 6:54 pm

  4. Maan .. you ripped them (yourself? :P) apart!

    Seriously though .. in terms of the system here where med school begins after undergrad, where would you place an MBBS graduate or a house surgeon? 1st year of med school? 2nd? Intern? Resident?

    BrownSandokan

    April 29, 2008 at 7:00 pm

  5. BrownSandokan – lol …had to vent this out some time or the other :-) . It really does get frustrating. Under India’s system, you’re classified as an undergrad student for the entire length of the course – 5.5 years. You can’t be called a ‘graduate’ without having received your degree first and that happens at the end of those 5.5 years. Even if your superiors/clerks do think of you so in their deprived wisdom.

    As far as equivalency between the US and Indian systems goes, the two are pretty disparate, making comparisons quite awkward. Under the US system students graduate at the end of 4 years, while students in India do so at the end of 5.5 years. In the US, quite interestingly, the first year of post-graduation/residency training is called the ‘internship’ year. Another point of distinction is that unlike students in India, students from the United States have pretty good hands-on training right from the first or second year of their curriculum. Indian students on the other hand, develop many of these skills in their last (i.e. 5.5th) year. I would equate the 5.5th year Indian student to the 4th year US student. They’ve more or less reached the same level of seniority in terms of their subjects.

    Even within the US, there are two basic categories of med schools – ‘traditional’ and ‘problem based learning’ types. Students belonging to these two different systems may not necessarily deal with the same subject matter during similar stages in their curricula.

    Firas MR

    April 29, 2008 at 7:28 pm

  6. ….this comment was deleted at the request of the author.

    alchemystical

    August 27, 2008 at 7:37 pm

  7. […] doesn’t do well for us. Take Evidence-Based-Medicine (EBM) for example. One of the reasons, why people make errors in interpreting and applying EBM in my humble opinion, is precisely because of the naivete that such a vacuum allows to fester. What […]


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