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 Table of Contents  
EDITORIAL
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 1-3

Evidence-Based Medicine: New Paradigm Towards Sound Medical Practice


Former Professor and Head of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr Venkateswaran Ramkumar
“Prakrithi”, D/95-A, Ananthnagar 2nd Stage, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_13_19

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How to cite this article:
Ramkumar V. Evidence-Based Medicine: New Paradigm Towards Sound Medical Practice. Airway 2019;2:1-3

How to cite this URL:
Ramkumar V. Evidence-Based Medicine: New Paradigm Towards Sound Medical Practice. Airway [serial online] 2019 [cited 2019 Jun 17];2:1-3. Available from: http://www.arwy.org/text.asp?2019/2/1/1/257047



The last issue of this Journal carried an Editorial on Creating the Indian Airway Guidelines and Beyond.[1] This time around, we would like to emphasise the need of the hour, evidence-based medicine. Evidence-based medicine is the integration of the best research evidence, clinical expertise and patient needs that will result in best patient outcomes.[2] Several aspects of medical practice in many countries still remain dogmatic. Treatment principles are often passed on from one generation to another. Over a period of time, the boundary between science and art becomes blurred leading to practices that are not really backed with evidence. Most practitioners of any speciality of medicine base their practice on what is described in 'standard textbooks'. Medical knowledge is advancing at such a rapid pace that if one were to wait for 'evidence' to percolate into 'standard textbooks', one would be left way behind currently available evidence, making one's practice quite dated.

Yet another angle to this problem is that some Indian practitioners tend to base their practice on books that originate from other countries. This may seem justifiable at face value, especially if such treatises are not available in our country. However, if one were to take the evidence that is drawn from a totally different population set in another country and try to apply that to a subset of the population in our country, the outcomes may be quite different. Unfortunately, documentation of medical records has also been less than optimal in many specialities in India. There is a dire need for us to develop our own evidence through properly conducted research on the Indian population. Based on such research, we need to develop our best practice guidelines and algorithms that are applicable to the specific circumstances under which we practice our discipline in India.

Let us take the speciality of anaesthesiology as an example. Several countries have created their own best practice guidelines in anaesthesiology. One might argue as to why one needs to reinvent the wheel when several senior practitioners, albeit from another country, have already created a recipe for success in their country that we could easily borrow. Let us pause for a moment and give this a thought. Would incorporating guidelines (developed to work under different circumstances in another country) into our practice in India ensure that we will be able to reproduce the same outcomes and reach the same standard of care in our practice as well? It would be naïve to think that this would happen. India is a vast country, and the practice of medicine (anaesthesiology being no exception) varies greatly not only from one state to another but also within a state between the 'no-frills' Government hospitals and the 'ultramodern 5-star' hospitals located in the corporate sector. Therefore, one can appreciate the urgent need for us to be insightful of our own practices. One needs to critically appraise the way we practice our speciality and be aware of the likely outcomes of our practice as per our own guidelines.

One way to overcome this problem is for us to make a concerted effort to create our own database. This should be done initially to cover major areas of practice in our discipline before going on to the less important areas. The first step is to define a specific question that needs to be answered. This question should be framed in such a way that it should be neither too narrow nor too wide in its scope. Questions that cover both extremes would be less useful when one embarks upon developing one's own practice guidelines. One should search for current evidence in the Indian population through primary research papers addressing the specific question that one is interested in. The evidence presented in such studies should be carefully evaluated, making sure that there is no bias in data collection or its interpretation. The principles spelt out by the results of such research would then provide the framework around which practice guidelines appropriate for our country could be created. The final step is to apply this to one's future practice. Further down the line, one could perform another audit to assess whether the changed practice has yielded better patient outcomes.

One can, for example, conduct an audit on the quality of patient monitoring in the operating room. Indian standards for patient monitoring have been laid down by the Indian Society of Anaesthesiologists.[3] Do we really adhere to these standards laid down by our professional society in all its wisdom? If not, why? Anaesthesiologists must stand united when patient safety issues are jeopardised by pressures from surgeons and hospital administrators alike. We are often asked to cut corners when it comes to patient safety issues. If we stay united in our belief, there is nothing that we cannot achieve. No force in this world can make us go against the Hippocratic Oath pledged by us. In the same vein, we do have Airway Management Guidelines that have been in circulation since December 2016.[4],[5],[6],[7],[8] It is not complimentary when senior Indian anaesthesiologists speak at national and international forums quoting all airway guidelines but the ones that were enunciated by their Indian counterparts through the committee created by the All India Difficult Airway Association >2 years ago. Is it possible that one does not give a second thought to something that has originated in one's own country? We cannot seem to get over our fascination for something that is 'foreign'. How many anaesthesiologists have applied their minds to what has been described in these Indian Airway Management Guidelines? How many have got back with constructive feedback stating what they believe is good and what they feel is objectionable in the guidelines as they exist? Writing in your views into speciality journals that cover these specific areas of our practice will form the crucible where such important matters get discussed and purified over time. We do have enough expertise within our country whose inputs could be extremely useful not only in clarifying our concepts but also in improving our own practice guidelines, making them more relevant to the Indian scenario. Clarity begins at home.

We need to have a system where critical incidents are reported to a common forum after concealing any information that would indicate where the incident originated from. Having a team of experts comment on the details of such incidents will undoubtedly be a huge learning exercise for all concerned. Just as we have a 'debrief following simulation-based learning', critical incidents should be discussed threadbare in a scientific forum within a closed peer group. If one avoids the name, blame and shame game that sometimes accompanies divulgence of such medical misadventures, the entire exercise will prove useful for all concerned. It is often said that history should repeat itself, but only for the good. We need not make the same grievous mistakes over and over again to mend our practice. One can and should learn not only from one's own mistakes but also from the mistakes unknowingly committed by one's colleagues. And how will one get to know about such misadventures unless one shares one's failures also. Articles published in journals by and large reflect only success stories. Even a single case that reports a crucial 'system breakdown' can be a huge learning exercise for the future and should therefore be published.

In medicine, one can never hang up your boots and say that one has learnt everything that there is to be learnt. Remember that doctors should stay abreast with all the developments in their field of specialisation. Being a doctor implies lifelong learning. The need of the hour is research that is based on our population. I appeal to all research-minded members of the fraternities of anaesthesiology, anatomy, biomedical engineering, emergency medicine, intensive care, maxillofacial surgery, nursing, operation theatre technology, otorhinolaryngology, pharmacology, physiology and respiratory therapy (listed alphabetically) to contribute their valuable airway-related research to the 'Airway' journal. Let us begin with young brilliant minds contributing their knowledge to a young journal. Over a period of time, we will have our own huge database that we can work on. This body of information can then be critically evaluated by leaders in their respective disciplines and applied to the way we practice these disciplines in India. 'Huh, armchair dream', one might say. But to borrow from the title of a book by Ronnie Screwvala, 'Dream with your eyes open', one can never achieve anything in life unless one dreams of change. And never be afraid to let your dreams run wild. Just as tiny drops of water make a mighty ocean, every single tree and bush contributes to a huge forest. Be the change you want to see.



 
  References Top

1.
Myatra SN, Ramkumar V. Creating the Indian airway guidelines and beyond. Airway 2018;1:1-3.  Back to cited text no. 1
  [Full text]  
2.
Strauss SE, Richardson WS, Glasziou P, Haynes RB. Evidence-based Medicine: How to Practice and Teach EBM. 3rd ed. Oxford: Churchill Livingstone; 2005.  Back to cited text no. 2
    
3.
Indian Society of Anaesthesiologists: Monitoring Standards for Providing Anaesthesia. Available from: https://www.isaweb.in. [Last accessed on 2019 Apr 07].  Back to cited text no. 3
    
4.
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Ramkumar V, Dinesh E, Shetty SR, Shah A, Kundra P, Das S, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in obstetrics. Indian J Anaesth 2016;60:899-905.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Pawar DK, Doctor JR, Raveendra US, Ramesh S, Shetty SR, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in paediatrics. Indian J Anaesth 2016;60:906-14.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Kundra P, Garg R, Patwa A, Ahmed SM, Ramkumar V, Shah A, et al. All India Difficult Airway Association 2016 guidelines for the management of anticipated difficult extubation. Indian J Anaesth 2016;60:915-21.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Myatra SN, Ahmed SM, Kundra P, Garg R, Ramkumar V, Patwa A, et al. The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the intensive care unit. Indian J Anaesth 2016;60:922-30.  Back to cited text no. 8
[PUBMED]  [Full text]  




 

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