The Evidence Network

Evidence based - medicine, health care, nursing - and other variations abound.

Having requested a subscription regularly into my inbox pops the The Evidence Network's newsletter c/o Alan Gomersall, at the Centre for Policy & Practice, King’s College London.

This issue - includes a number of recent reports from the Social Policy & Practice database which appear to be relevant to EBPP (evidence-based policy and practice), as well as the usual coverage of new services, forthcoming conferences and courses etc.

Associates Network

The Associates Network fosters contact between members of a diverse and growing EBPP community. Membership is free, but you must be an active researcher or practitioner with a particular interest in evidence-based policy and practice issues. Benefits include:

• access to the Associates database of the activities, interests and contact details of over 1,350 members of the Network worldwide
• a regular email newsletter, to which you can contribute
• an opt-in email discussion group
• a discounted subscription to the peer reviewed journal Evidence & Policy.

I've tried to capture some key resources on the SCIENCES links page - must make sure this network is there.

h2cm = Bayesian Quarters?

INTERPERSONAL : SCIENCES

SOCIOLOGY : POLITICAL

The Bayesian approach allows human insight, subjective though it is, to be combined with statistical information, limited though it may be. It is not surprising that this blurring of the line between the methodologies of the sciences and the humanities has attracted passionate supporters as well as furious enemies on both sides of the cultural divide.

Von Baeyer (2003) p.79.

von Baeyer, H.C. (2003) Information: The New Language of Science, Weidenfeld and Nicolson, London.

h2cm and clinical equipoise

The past few weeks reading the Journal of Evaluation in Clinical Practice - I've encountered the concept of equipoise: specifically the clinical form.

The Health Career - Care Domains - Model is all about 'poise'.

The model's care domains provides the perfect workout.

Medicine, health and social care constantly exercises us. We are whether or not we recognize it on a balance board. In fact if you consider that image and then factor in the complexity of health care today you realise just how much stuff (technology), how many people (subjects, agents) need to be on that same board. Who does the board belong to though? Well of course it's -

Jo (off-balance, strengths depleted, sick (and tired), prone to relapse, bank poleaxed...) Public's !

The April 2010 issue of the above journal is a fascinating read. I noticed today that some of our placement students were not aware of the recent and current position regarding health policy: that is the 'long view' of decades such as: Health of the Nation, the National Service Frameworks, Darzi ... They need to address that and I'm sure they will.

This journal issue prompts me to consider evidence based medicine anew, especially:

• How long it's been around - some 20 years.
• Its occupying the SCIENCES domain, with its weight threatening to overbalance all (you could say it's a significant singularity).
• The realization that the Emperor is short on clothes.
• Given the above it can mature. Bogdan-Lovis and Holmes-Rovner (2010)

Back to that board: and stepping onto the health care domains - all four of them so spread your feet - you can see instantly (feel that feedback) how EBM, shared decision making and (person) patient-centered care are all related. As Bogdan-Lovis and Holmes-Rovner (2010) highlight:

Equipoise is the heart of the shared decision making movement, and it embodies the problems for which patient decision aids are most often developed to explain the risks and benefits of competing alternatives. p.377.

h2cm is well suited to this task on so many levels.

The past week or two I've also noticed several mentions of the need to nudge people - here and there - both in the media and in Bogdan-Lovis and Holmes-Rovner's paper and references.

More to follow - and as you step-off take care ....

Wilson, K. (2010) Evidence-based medicine. The good the bad and the ugly. A clinician's perspective. Journal of Evaluation in Clinical Practice, 16, 398-400.
Bogdan-Lovis, E., Holmes-Rovner, M. (2010) Prudent evidence-fettered shared decision making. Journal of Evaluation in Clinical Practice, 16, 376-381.

And for the week ahead:
One mind, many minds - ONE PLANET. One need, many needs - ONE PLANET: what price stability?
http://hodges-model.blogspot.com/2009/02/one-mind-many-minds-one-planet-one-need.html

Bursary applications - 17th Oxford Workshop on Evidence-Based Practice

Dear Colleagues,

The Centre for Evidence-Based Medicine is offering three free bursary places on the -

17th Oxford Workshop on Teaching Evidence-Based Practice.

Applicants will need to cover their travel and accommodation costs.

All applicants should send a covering letter with their application (which can be downloaded at www.cebm.net) detailing their current involvement with Evidence-Based Practice and outlining what they would do with the knowledge gained on the workshop. Applicants should also enclose a current C.V..

All applications should be sent to me at the address at the bottom of this email. Closing date for applications is 31st March 2011.

I should be grateful if you would disseminate this email to any and all interested parties.

The 17th Oxford Workshop on Teaching Evidence-Based Practice will be held 5th - 9th September 2011 at St. Hugh's College, Oxford, UK and is aimed at clinicians and other health care professionals, including those involved in mental health, who already have some knowledge of critical appraisal and experience in the practice of evidence-based health care and who want to explore issues around teaching evidence-based medicine.

There will be two main themes running throughout the workshop:

Teaching will be addressed through the exploration of different educational models for teaching evidence-based practice and identification and discussion of issues of pedagogy, curriculum design development and maintenance. The aim will be to promote the teaching of evidence-based health care at your home institution.

Personal Development will be addressed by offering guidance and help in extending and advancing participants' existing critical appraisal and teaching skills.

All good wishes,

Olive

Olive Goddard
Centre and Editorial Manager
Centre for Evidence-Based Medicine
Department of Primary Health Care
Old Road Campus, Headington
Oxford, OX3 7LF
............................................................
email: olive.goddard AT dphpc.ox.ac.uk
 www.cebmh.com

My source: CEBMH-MEMBERS AT JISCMAIL.AC.UK

Rhinos, evidence based medicine and 'out-reach'

It would be be marvellous to be able to introduce h2cm to the nursing, health and social care communities in Asia, especially China. According to Flag Counter just two visitors. There are the good - effective ways of doing that and the not so good. How the following measures up I'm not sure...

Working in health we are surely aware of the need to base what we do on evidence. Although nurses are not necessarily independent as the patient advocate. Advocacy is still an important part of the nursing role and one requiring specific advice in some instances.

Earlier this month a Guardian article related the ever more precarious position of the South African rhino and how claims about the curative properties of rhino horn as a medicine fuels poaching. The UK is nowhere near South Africa or China so what gives? What gives is the Planet, the tiger too and the biosphere in general. Apparently rhino horn is just compacted keratin and has no medicinal properties.

Nurses tend to be a green, ecologically minded group and the best source of change comes from within. It is never easy to change the beliefs of others, especially when your culture venerates its elders. Belief also remains a powerful factor in health. Despite this do nurses not have a duty to challenge beliefs that are wrong, to educate their communities?

What price true literacy: spiritual, 3Rs, ICT, health, environmental ....?

There must be a way for nurses to unite on this - 

across cultures, borders, digital barricades, politics, beliefs ....

As we make a difference individually with patients and carers ... collectively can we extend our reach to other communities too? While there's still time - and we try not to bite our nails.

Interesting and clearly ironic in the UK that after a generation public health is to have a new service with a return to the local authorities.

Grand Challenges for Global Health: 15th - access to clean, clear, knowledge

Dear HIFA2015 colleagues,

The news item below is forwarded from the Global Health Council, which reports the mHealth Summit taking place this week in washington DC. It is especially good to see that Bill Gates is giving a keynote address. This suggests that the Gates Foundation may be poised to address the 15th Grand Challenge for Global Health, as proposed by international health leaders in The Lancet:

"The Gates Foundation identified fourteen challenges [Grand Challenges for Global Health] but a fifteenth challenge stares us plainly in the face: The 15th challenge is to ensure that everyone in the world can have access to clean, clear, knowledge - a basic human right, and a public health need as important as access to clean, clear, water, and much more easily achievable."

Tikki Pang (WHO), Muir Gray (NHS, UK), and Tim Evans (WHO): 'A 15th grand challenge for global public health.' The Lancet 2006; 367:284-286.
http://www.thelancet.com/journals/lancet/article/PIIS0140673606680501/fulltext

When HIFA2015 was in planning back in 2006, the lead author of the above paper, Dr Tikki Pang (Director of Research policy and Cooperation at WHO) said: 'HIFA2015 is an ambitious goal but it can be achieved if all stakeholders work together'. Bill and Melinda Gates are critical stakeholders. I look forward to see Bill Gates' presentation. Will the Gates Foundation take up the 15th Challenge? Will the Gates Foundation prioritise the challenge of health information for all by 2015?

Bill Gates keynote yesterday is not yet available on the web, but it will be soon at: http://mhealthsummit.org/conference/live-webcast

I hope that Bill Gates will use this opportunity to articulate a clear and specific vision from the Gates Foundation: a vision of a world where people are no longer dying for lack of access to appropriate, reliable healthcare information. With their support, there is no doubt this vision can and will be realised.

With best wishes,
Neil

HIFA2015 profile: Neil Pakenham-Walsh is the coordinator of the HIFA2015 campaign and co-director of the Global Healthcare Information Network. He started his career as a hospital doctor in the UK, and has clinical experience in rural Ecuador and Peru.  For the last 20 years he has been committed to improving the availability of healthcare information for health workers in developing countries. He has worked with the World Health Organization, the Wellcome Trust, Medicine Digest and INASP (International Network for the Availability of Scientific Publications). www.hifa2015.org  neil.pakenham-walsh AT ghi-net.org

My source:  www.hifa2015.org

The Empowered Patient Conference

HIFA2015 brought this conference to my attention rather late, but it is nonetheless well worth posting. Indirectly for the health career model, which can facilitate patient and carer education and empowerment. In addition to demonstrating the global potential of h2cm this announcement also demonstrates how small the world is becoming. I had the pleasure of hearing Mark Duman present in Manchester at a local BCS medical informatics meeting in the spring. I've since maintained a link to the Patient Information Forum here on W2tQ and Links III - 'Patients, Carers & Self-Care'.

If you are organising a conference or event for 2011 ... please let me know. I may be able to assist with free publicity on the care domain pages interpersonal, sciences, political or sociology - especially if your themes are similar: nursing, informatics, education, global health, self-care. ...

HELP is pleased to organize The Empowered Patient Conference in Mumbai on 20 October. The website is at http://www.patientpower.in/

Traditionally, Indian patients were passive and were quite happy to leave all medical decisions to the doctor. However, times have changed, and internet positive patients are hungry for information and want to work in partnership with their doctor. This is a huge challenge - and a great opportunity as well. We feel patients are the largest untapped health care resource and that Information Therapy is Powerful Medicine!

In partnership with the Patient Information Forum, UK, HELP is organizing The Empowered Patient Conference. Our keynote speaker will be Mr Mark Duman, President of PiF:
http://www.pifonline.org.uk/home/

Information Therapy can help patients (and health insurance companies!) save money on medical care by:

1. Promoting SelfCare and helping them to do as much for themselves as they can.
2. Helping them with Evidence-Based Guidelines, so that they can ask for the right medical treatment that they need - no more and no less.
3. Helping them with Veto Power, so they can say No to medical care they don’t need, thus preventing overtesting and unnecessary surgery.

Information Therapy is good for doctors and hospitals as well, as patients who are well-informed have realistic expectations of their treatment. They are much more likely to have a good medical outcome and much less likely to sue.

How can we all work together - doctors, patients, hospitals, health insurance companies and IT companies, to ensure that patients are at the heart of everything we do in healthcare?

Dr Aniruddha Malpani, MD
Medical Director
HELP - Health Education Library for People
Excelsior Business Center,
National Insurance Building,
Ground Floor, Near Excelsior Cinema,
206, Dr.D.N Road, Mumbai 400001

Helping patients to talk to doctors! Information Therapy is the Best Prescription!
Read over 20 health books free at www.helpforhealth.org
Read my blog about improving the doctor-patient
Relationship at http://doctorandpatient.blogspot.com/
Join India’s first health wiki at www.myhealthpedia.in

Book: "Outcome Measurement in Mental Health" Cambridge University Press

Outcome Measurement in Mental Health
Theory and Practice
Edited by Tom Trauer
Hardback
Published June 2010

In order to operate in an evidence-based fashion, mental health services rely on accurate, relevant, and systematic information. One important type of information is the nature of the problems experienced by recipients of mental health care, and how these problems change over the course of time. Outcome measurement involves the systematic, repeated assessment of aspects of health and illness, either by service providers, service recipients, or both. From outcome measurement clinicians and service recipients achieve a common language whereby they can plan treatment and track progress, team leaders and managers secure a basis to compare their services with others and to promote quality, while policy makers and funders derive evidence of effectiveness. This book will be an essential and practical resource for all members of the mental health clinical team as well as those responsible for establishing or managing services, and directing policy.

• Presents a global perspective on outcome measurement enabling readers to compare and contrast practices around the world
• Enables readers to identify the specific challenges presented in different groups and settings, the instruments to use, and how to use the results
• Emphasizes the relevance and use of outcome data to clinicians, to help them improve their effectiveness

Contents

Preface; 1. Introduction Tom Trauer; Part I. Outcome Measurement Around the World: 2. Mental health outcome measurement in Australia Jane Pirkis and Tom Callaly; 3. Outcome measures in New Zealand Graham Mellsop and Mark Smith; 4. Outcome measurement in England Mike Slade; 5. Outcome measurement in Ohio and the United States James Healy and Dee Roth; 6. The outcome questionnaire system: a practical application for mental health care settings Michael J. Lambert; 7. Outcome measurement in Italy Mirella Ruggeri; 8. Outcome measurement in Germany Sylke Andreas, Thomas Becker, Holger Schulz and Bernd Puschner; 9. Outcome measurement in mental health services in Norway Torleif Ruud; 10. Outcome measurement in Canada: one province's experience with implementation in community mental health David Smith; Part II. Outcome Measurement in Specific Groups and Settings: 11. Routine outcome measurement in child and adolescent mental health Peter Brann; 12. Outcome measurement in adult mental health services Tom Trauer; 13. Outcome measurement in older persons Rod McKay and Regina McDonald; 14. Outcome measurement with indigenous consumers Tricia Nagel and Tom Trauer; 15. Routine measurement of outcomes by Australian private hospital-based psychiatric services Allen Morris-Yates and Andrew Page; 16. Mental health outcome measurement in Non-Governmental Organizations (NGOs) Glen Tobias; 17. Outcome measurement in drug and alcohol services Maree Teesson and Mark Deady; Part III. Current Issues in Outcome Measurement: 18. Outcome measurement - applications and utility Tom Trauer; 19. Stakeholder perspectives in outcome measurement Tom Trauer; 20. Assessment of change in outcome measurement Tom Trauer; 21. Routine outcome measurement: perspectives on skills and training Tom Trauer and Tim Coombs; 22. A review of instruments in outcome measurement Tom Trauer; 23. Some economic and policy considerations for outcome measurement Rowena Jacobs; 24. Future directions Tom Trauer; Index.

http://www.cambridge.org/uk/catalogue/catalogue.asp?isbn=9780521118347

My source:
UK Routine Clinical Outcomes Network Forum

Issue 2, 2009 of The Cochrane Library

Issue 2, 2009 of The Cochrane Library is now available. Among the new and updated Cochrane Reviews you will find :

• Homeopathic medicines for adverse effects of cancer treatments
• Music for stress and anxiety reduction in coronary heart disease patients
• Interventions for preventing falls in older people living in the community
• Extraction of primary (baby) teeth for unerupted palatally displaced permanent canine teeth in children
• Psychological therapies for the management of chronic pain
• Topical treatments for chronic plaque psoriasis
• Alcohol and drug screening of occupational drivers for preventing injury
• And many more … www.thecochranelibrary.com

Some of these reviews have been highlighted in Evidence Podcasts and are free to access.

Please see the Release Notes for a summary of the updates in this issue. Users can also access our Highlights PDF to learn more about the findings of new and updated Cochrane Reviews.
The Cochrane Library

The Cochrane Handbook for Systematic Reviews of Interventions is now available in print format. It is published by John Wiley for The Cochrane Collaboration.

Editors: Julian P. T. Higgins MRC Biostatistics Unit, Cambridge, UK Sally Green Australasian Cochrane Centre, Monash University, Melbourne, Australia

There is a 25% discount for Cochrane Review authors and an information page for the book where authors can also order, with a prompt to enter their discount code.

Wiley authors are entitled to a 25% discount not only on their own titles, but on all Wiley books, when ordering either via the site, by phoning customer services or filling in any printed order forms.

Sign up now for the Author Discount club by filling in the registration form. You will be sent a discount club card with a special promotion code printed on it. You will need this to order via on-line through the shopping cart (just type in the code in the discount information field) or through our customer services department.

Free Training and user guides:
Instructor-led virtual training sessions on The Cochrane Library. Self-paced online tutorials.

For User guides and Powerpoint presentations see the Help page on - Cochrane Library


Images and my source: John-Wiley mail-list

Squaring circles: Compressed patient care pathways = rich(er) patient experiences?

The use of Lean and Six-Sigma, their combination and other service improvement approaches has resulted in much more effective patient care pathways. A shining example is that of diagnostic medicine and subsequent out-patient appointments, apparently patients can attend for diagnostic services such as imaging and on the same day also attend for their first out-patient appointment. This saves time for all, with expensive imaging technology also proving its worth and RoI by working from 0700-2200.

Trust Boards are well pleased with such progress, but there is no such thing as a free lunch. Managers and execs know the lunch (diagnostics and imaging) isn't free, but quantitative aspects aside what does does this mean in terms of quality and assurance? Quality in the sense of:

• patient (and carer) experience;
• staff capacity to find and take advantage of patient learning (self-care, patient health career management) opportunities;
• assessment and evaluation of patient (carer) comprehension;

There is a circle to be closed by relating quality to quantitative aspects; such as, re-referral rates, re-admission, medication / treatment concordance, plus the infusion of intelligence from local and national patient related outcome measures [PROMS] to new patient journeys.

In information science there is the concept of information compression, taking out the redundancy - repetitive data in an image or text to save on processing, transmission, and storage. As Lean Six Sigma assists teams to remove tasks, processes that do not 'add value' then the result is a richer experience. The patient journey has in this sense been compressed. The patient has fewer hospital and clinic visits with fewer bus, taxi journeys, or they pay less in car park fees. Health personnel and specialists are primed to help and deliver services that really count.

What does this compressed - 'denser' experience - mean though? Does it mean that:

• patient's are exposed to more information (2-3 significant interviews / leaflets / instructions)?
• there is less time available for education, health promotion, info Px giving?

- or alternately:

• does this 'value packed' patient journey help by providing rapidly successive hooks - experiential threads to integrate patient (carer and staff!) learning?

It will be interesting to see answers to these questions and how extensive the scope of benefits are of these patient experiences across different care contexts.

Is there an optimal number for 'clinical encounters' before things start to go awry?

PROMS are quite specific (as they need to be initially), but amid richer and varied patient journeys there will be a need for other (national and local) measures. What about the extent and level of 'care complexity' and 'holistic care'?

Additional links:

Lesley Wright on lean thinking and respecting NHS staff, HSJ, Dec 2008.

NHS ready for PROM date. NDS News Distribution Service.

Image source: http://www.navyenterprise.navy.mil/knowledge/tools/sixsigma.aspx

The Science Collaboration Framework (SCF)

My attention was drawn today (by Robert Douglas) to The Science Collaboration Framework (SCF) that is based on Drupal.

Here are some details from the SCF website:

About:

Interdisciplinary research programs at Harvard and elsewhere naturally tend to be distributed geographically, across campuses and departments. Effective collaboration for these programs requires the ability to bridge distance, which in turn implies digital collaboration, and therefore abilities to publish and discuss on-line content such as articles, news, and perspectives; to provide semantic context to on-line content for more powerful interactions within multiple sub-disciplines and to integrate as well as distinguish the individual contributions of many scientific workers.

The Scientific Collaboration Framework (SCF) is reusable software that can be used to develop web-based, collaborative, scientific communities. The framework is designed to support interdisciplinary scientists in publishing, annotating, sharing and discussing content such as articles, perspectives, interviews and news items, as well as assert personal biographies and research interests – the basics of any online community. These web materials can then be linked to external, heterogeneous knowledge repositories of life science resources such as genes, antibodies, cell-lines or model organisms. SCF, thus supports structured “Web 2.0” style community discourse amongst researchers, makes various data resources available to the collaborating scientist and captures the semantics of the relationship among the discourse and resources.

Our framework is based on Drupal – a popular content management system that is highly extensible and has a thriving ecosystem of contributed modules. SCF includes new modules for managing publications, interviews, member information, news items, announcements, and biological entities (e.g., genes). The framework is freely available as a Drupal distribution; however the modules can be used a la carte as well.

SCF is a project of the Initiative in Innovative Computing at Harvard University in collaboration with the Harvard Stem Cell Institute. The first instance of SCF is being adopted by StemBook (stembook.org) – a comprehensive, open-access collection of original, peer-reviewed chapters covering topics related to Stem Cell Biology. A joint project with Michael J Fox Foundation (MJFF) to develop a community site for Parkinson's researchers is under development. SCF is also being evaluated by several other communities.

Publications:
Sudeshna Das, Tom Green, Louis Weitzman, Alister Lewis-Bowen & Tim Clark. Linked Data in a Scientific Collaboration Framework. 17th International World Wide Web Conference (WWW2008), Beijing, China.

I am particularly interested in SCF since as noted above "the modules can be used a la carte as well." The potential of putting this together with the Drupal Education distribution is really exciting. I still believe that SVG (or similar) has a role to play for my plans. In the meantime though back to Drupal version 6.9....

Additional links:

Alzforum
R. Douglas at Drupal.org
WWW2009 Madrid

Centre for Evidence-Based Medicine invites applications for bursary places 15th Oxford Workshop on Teaching Evidence-Based Health Care

The Centre for Evidence-Based Medicine invites applications for bursary places on the 15th Oxford Workshop on Teaching Evidence-Based Health Care.

This workshop will take place
7th - 11th September 2009
at St. Hugh's College, Oxford, UK.

Applications for bursary places should enclose a CV plus a letter detailing their current involvement in evidence-based practice and outlining what they would do with the knowledge gained on the workshop.

The workshop is aimed at clinicians and other health care professionals, including those involved in mental health, who already have some knowledge of critical appraisal and experience in the practice of evidence-based health care and who want to explore issues around teaching evidence-based medicine. The workshop is NOT intended to serve as an introduction to evidence-based medicine itself.

There will be two main themes running throughout the workshop:

Teaching will be addressed through the exploration of difference educational models for teaching evidence-based practice and identification and discussion of issues of pedagogy, curriculum design development and maintenance. The aim will be to promote the teaching of evidence-based health care at your home institution.

Personal Development will be addressed by offering guidance and help in extending and advancing participants’ existing critical appraisal and teaching skills.

All bursary applications will be considered at the end of March.

The bursary will cover the complete workshop fees, but applicants will need to obtain their own funding for accommodation and travel.

All good wishes,

Olive

Olive Goddard
Centre and Editorial Manager
Centre for Evidence-Based Medicine
Department of Primary Health Care
Old Road Campus, Headington
Oxford, OX3 7LF
.....................................................................
Tel: +44 (0)1865 289337 email: olive.goddard @ dphpc.ox.ac.uk
Fax: +44 (0)1865 289336 web: www.cebm.net/
web: www.cebmh.com ( http://www.cebmh.com )

Evidence Based Medicine & Care and the I-G Nexus

Great store is placed upon evidence based medicine (EBM), nursing and care. There are dedicated centres, conferences (1 , 2, 3..), journals, policy pronouncements and much more besides.

The evidence based approach has been subjected to critical review in leading health, medical and research journals and blogs. The status and presence of EBM as the bridge between clinical theory and practice is not in question, it is only right however that nothing is taken for granted. EBM is not necessarily as scientific - as objective - as the clinical trials and meta-analyses... make it appear.

Dr Nicholas Hicks provides a brief and yet informative piece on the definition and scope of evidence based health care on Bandolier.

The success of EBM depends however on the GROUP: the sensitive aggregation of results with the personal details stripped out (anonymised). EBM is still (rightly) subject to debate, its method and methodologies constantly scrutinised. In terms of contemplating the complete care spectrum Hodges' model places the natural home of EBM as being grounded in the SCIENCES domain. The POLITICAL domain provides a vital, supportive and reinforcing role through policy, governance and reporting, nationally and internationally. Subsequent studies are modified and refined to ensure lessons are learned.

The ongoing challenge that the application of EBM&HC presents can be found in h2cm, if we choose to reflect there. What we must never forget is that the benefits of EBM are delivered to INDIVIDUALS. Ultimately, it is they who benefit from improvements in treatments and care. It is the individual who remains at the centre of care.

"Evidence based" approaches are being applied in a great many disciplines, but it is the notion of EB care (EBC) as Hicks writes that deserves our special attention. Thinking back to basic physical nursing care c. late 1970s: whilst the best treatment for pressure sores is prevention, this is one area that has benefited enormously from evidence based research. For decades pressure sore treatment and care variously relied upon custom and practice, the myth of Sister x, y, z (or "we do it this way..."), to scientific scramblings, argument and debate.

EBM has recognised the need for quality as well as quantity.

There may also be a stark contrast between the time-scales of EBM and EBC?

If we split "EB" and the "C", we see that there is a danger that the 'I' may get lost:

• To what extent is EBM situated, such that the patient would also recognise the context?
• To what extent is EB(x) a baton for best practice? -
  
• That is, from the start lines in research lectures, learned journals, research supervision and international study centres - how easily is EB(x) transferred to wards and other clinical areas? (Having 'best practice' examples is the just the start: how will these be communicated?)
  
• Are the notions of 'holistic assurance and bandwidth' applicable and of value here?
• Is EBC patient AND staff empowering? Is EBC like EBM supported by the underlying (political domain's) foundation of policy and audit to ensure that change does happen and staff can deliver safer, more effective, individualised, person-centred care?
  

The best evidence is that gleaned from the source. This does mean the non-trivial task of juggling subjective and objective health. It means engaging with the patient and community. It means that the best evidence for care should also be timely. This may be a fuzzy form of EB(x), but in contrast to the steel bearing that EBM can often present, there are plenty of hooks that can make a real difference.

Source:
Sullivan, M. (2003). The new subjective medicine: taking the patient's point of view on health care and health. Soc. Sci. Med. 56(7), 1595-604.

Resource:
http://www.pickereurope.org/

Image sources:
http://www.leroi.com/index.php?p=view_product&product_id=11416
http://photography.qj.net/tags/nikon/326