Fernandez Ana, Sturmberg Joachim, Lukersmith Sue, Madden Rosamond, Torkfar Ghazal, Colagiuri Ruth, Salvador-Carulla Luis
Brain and Mind Centre, Faculty of Health Sciences, The University of Sydney, 94 Mallett Street, Camperdown, NSW, 2050, Australia.
Discipline of General Practice, School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia.
Health Res Policy Syst. 2015 Nov 6;13:66. doi: 10.1186/s12961-015-0057-0.
This paper aims to describe the contextual factors that gave rise to evidence-based medicine (EBM), as well as its controversies and limitations in the current health context. Our analysis utilizes two frameworks: (1) a complex adaptive view of health that sees both health and healthcare as non-linear phenomena emerging from their different components; and (2) the unified approach to the philosophy of science that provides a new background for understanding the differences between the phases of discovery, corroboration, and implementation in science.
The need for standardization, the development of clinical epidemiology, concerns about the economic sustainability of health systems and increasing numbers of clinical trials, together with the increase in the computer's ability to handle large amounts of data, have paved the way for the development of the EBM movement. It was quickly adopted on the basis of authoritative knowledge rather than evidence of its own capacity to improve the efficiency and equity of health systems. The main problem with the EBM approach is the restricted and simplistic approach to scientific knowledge, which prioritizes internal validity as the major quality of the studies to be included in clinical guidelines. As a corollary, the preferred method for generating evidence is the explanatory randomized controlled trial. This method can be useful in the phase of discovery but is inadequate in the field of implementation, which needs to incorporate additional information including expert knowledge, patients' values and the context.
EBM needs to move forward and perceive health and healthcare as a complex interaction, i.e. an interconnected, non-linear phenomenon that may be better analysed using a variety of complexity science techniques.
本文旨在描述催生循证医学（EBM）的背景因素，以及其在当前健康背景下的争议和局限性。我们的分析运用了两个框架：（1）一种对健康的复杂适应性观点，即把健康和医疗保健视为从其不同组成部分中产生的非线性现象；（2）科学哲学的统一方法，为理解科学发现、确证和实施阶段之间的差异提供了新的背景。
对标准化的需求、临床流行病学的发展、对卫生系统经济可持续性的担忧以及临床试验数量的增加，再加上计算机处理大量数据能力的提高，为循证医学运动的发展铺平了道路。它基于权威知识迅速被采用，而不是基于其自身提高卫生系统效率和公平性能力的证据。循证医学方法的主要问题在于对科学知识的限制和简单化方法，该方法将内部有效性作为纳入临床指南的研究的主要质量标准。相应地，产生证据的首选方法是解释性随机对照试验。这种方法在发现阶段可能有用，但在实施领域并不充分，实施领域需要纳入包括专家知识、患者价值观和背景等额外信息。
循证医学需要向前发展，并将健康和医疗保健视为一种复杂的相互作用，即一种相互关联的非线性现象，使用各种复杂性科学技术可能会对其进行更好的分析。
