Introduction to EBM in developing countries
You are a facilitator in an EBM workshop conducted for a group of rural practitioners in a remote barrio in the Philippines. At the tail end of a small-group session on critical appraisal of articles on therapy, the discussion drifts to EBM in general, and how useful it can become for busy clinicians. Suddenly, an exasperated participant breaks his silence. "All of this science sounds real good, doctor, but I practice in a small town where I see really poor patients, who can hardly afford to eat. The nearest medical library is 3 hours away, and its shelves are almost empty. We don't have computers you know. In fact, we sometimes don't even have electricity. My question is this, how relevant can EBM be in our setting?" A silent pause follows, filled with tension, as you sit still, eyes downcast, trying to prepare a reply. It is an inevitable question that has been asked in different ways, for a countless number of times. Nevertheless, it remains a difficult question to answer. What would be your response?
The frustrations expressed by this rural practitioner are echoed by thousands of health care providers who attend to millions of patients in developing countries all over the world. The problems are depressing, and even for our sympathetic colleagues from the developed world, it may be difficult to understand the cynicism and desperation. Do we really need EBM in developing countries? What are the obstacles to practicing and teaching EBM? How do we hurdle these obstacles? This article attempts to answer these important questions, by drawing from experience in the Philippine setting.
Do We Really Need EBM in Developing Countries?
Consider the following reasons.
In many developing countries, the bulk of health care expenditures continue to be shouldered by individual patients or their families. These health care expenses must compete for extremely scarce resources. Thus, nothing could be more appalling than a physician ordering unnecessary tests or prescribing inappropriate treatments for indigent patients. All over the Philippines, for example, resting electrocardiograms (ECG) are routinely done in asymptomatic patients to screen for coronary artery disease or CAD1. The test alone costs approximately US$5.00, enough to provide three full meals for a family of 5. A careful appraisal of the evidence would have revealed to practitioners that resting ECG's are fraught with high false negative and false positive rates. These problems make it virtually useless as a screening instrument for CAD2.
As this example illustrates, the practice of EBM in developing countries could save millions of dollars in terms of health expenses. The ultimate beneficiary in a fee-for-service system would not be the government, because they make meager investments in healthcare anyway. Neither would it be the physicians, although EBM would make invaluable contributions towards improvement of their clinical practice. In fact, the ultimate beneficiaries of EBM would be the patients themselves, who may now spend their hard-earned money on more immediate needs -- such as food and shelter.
Limited capacity for drug regulation
Again because of limited resources, departments of health often falter in their role as regulators of the pharmaceutical industry. Approval of a drug for marketing becomes so easy that drugstores are flooded with a myriad of products, listed for questionable indications. A survey in 1994 showed, for example, that as many as 50% of patients with acute myocardial infarction received a class of drugs called "metabolic enhancers"3. These drugs include trimetazidine, co-enzyme Q10, and l-carnitine, which were approved as treatments for coronary disease, even if evidence of efficacy was lacking (at least at the time of the survey, and as of this writing).
When drug regulation is inadequate, as in many developing countries, physicians must expect an onslaught of technology and false claims. They must take up the cudgels and arm themselves, in defense of the patients they care for. EBM provides them an arsenal of easy weapons with which to achieve this task.
Limited capacity for continuing medical education
In the Philippines, and probably in many other developing countries, drug companies invest heavily in the process called continuing medical education (CME). Many medical societies and academic institutions are so poor, that "scientific meetings" would not be possible without soliciting such support from the pharmaceutical industry. On the surface, this may seem like an innocent relationship. In reality however, this has given industry nearly total control of the direction of CME, dictating the topic, as well as the speaker, at scientific sessions. This situation has dulled the distinction between drug promotion and education, and has converted society conventions into potent marketing instruments.
In 1996, for example, despite medical evidence favoring the use of beta-blockers over calcium channel blockers for hypertension, a local survey showed that only 17 % of hypertensive patients received beta-blockers, while as much as 62% received calcium channel blockers4. The less effective and more expensive drug was also the most commonly prescribed. Such a phenomenon can only be attributed to successful marketing and promotional activities. As this example shows, without EBM, false claims can roam the countriesside, free to ravage the scarce resources of our suffering patients.
How Do We Hurdle Obstacles to Practicing EBM in Developing Countries?
Justifying EBM in developing countries is easier than coming up with ways to hurdle the obstacles. In the following section we discuss some of the obstacles that have been pointed out by participants of our workshops. Some practical solutions are proposed.
Limited access to literature databases
How can one track the literature for answers to specific problems, when there are no facilities for conducting an efficient search? In this age of high-speed, mega-memory computers, many homes, hospitals and academic institutions continue to operate without even the most meager computer facilities. Even where there are computers, access to literature databases may be limited. Considering the benefits that can be attained however, the budgetary requirements aren't that steep. A basic desktop with a CD-ROM reader and MODEM could cost as low as US$900.00, and would be a worthwhile investment for any healthcare facility (provided there is electricity to run it). A year's subscription for MEDLINE on CD-ROM would cost a hefty US$450.00. An internet connection allowing 12 hours of MEDLINE access, on the other hand, would cost only about US$25.00 per month. Convincing administrative heads to invest in such facilities was a long but easy task in our departments. As EBM practitioners, we busied ourselves looking for opportunities to publicly cite how efficient searches helped us in our daily lives -- preparing for lectures, preparing research protocols, and even managing difficult patient problems in our services. Before long, unfamiliarity with literature databases led to curiosity, then to enthusiasm, and finally to purchase orders.
Another option resorted to was to request such equipment from pharmaceutical companies. Donations usually come with strings attached, but not always. With some effort, one can always find a well-meaning company willing to make small investments for purely altruistic reasons. At the very least, requests for such computers are more productive than requests for dinners, out-of-town trips or other frivolous needs of physicians. In many situations, all will fail and one will not be able to acquire or access a computer. Rest assured that this does not mean the end of the world. As will be discussed later in this article, there are other ways of practicing EBM.
Limited access to adequate library facilities
"We identified 5 relevant randomized controlled trials using our exhaustive search strategy. Today, we are presenting the results of the one article that we successfully retrieved." Such statements are commonly encountered in EBM conferences, grand rounds and medical audits, when well-meaning residents make a lame attempt to update their audience on the evidence surrounding a particular medical problem.
After conducting an exhaustive search for evidence, nothing could be more frustrating than a trip to the library, only to find that most of the journals you need are not on the shelves! The problem is a difficult one that can be traced to the inadequate library facilities that are almost inevitable in developing countries. Rather than wallow in misery and self-pity however, we have taken this challenge to task, with a modest amount of success. In one brainstorming session, a group of EBM practitioners developed a "literature retrieval algorithm" that harnessed the strengths of various possible sources of published literature. In this algorithm, attempts to retrieve articles move in sequence from the top 3 libraries in the countries (all of which in truth are small) to libraries of multinational drug companies, and eventually to individual friends or colleagues in other countries, who have access to their own library facilities. We maintain a big list of such "friends", in order to make sure that we do not abuse any individual's hospitality. Thus far, the system seems to work quite well, with retrieval rates of over 80%. We have not lost a whole lot of friends in the process.
Questionable applicability of journal articles that are eventually retrieved
What assurance does a practitioner have that a treatment that worked in a developed countries will work as well in his rural environment? The tempting answer is that we can never be sure, unless we duplicate all these studies in our own individual settings. It may seem obvious that this proposition is next to impossible, and yet, numerous studies have been conducted in our institution, which were based on such a proposition.
- Are there pathophysiologic differences in the illness under study that may lead to a diminished treatment response?
- Are there patient differences that may diminish the treatment response?
- Are there important differences in patient compliance that may diminish the treatment response?
- Are there important differences in provider compliance that may diminish the treatment response?
- Do my patients have co-morbid conditions that significantly alter the potential benefits and risks of treatment?
- Are there important differences in untreated patients' risk of adverse outcomes that might alter the efficiency of treatment?
Aside from helping clinicians decide if a trial result is applicable to a particular patient, these criteria have helped researchers decide exactly when these trials should be replicated.
How Do We Hurdle Obstacles to Teaching EBM in Developing Countries?
As there are hurdles to applying EBM, so too are there obstacles to teaching it. The problems listed below are those which we have commonly encountered in the conduct of EBM workshops throughout the countries. Again, some practical solutions are proposed.
Inexperience in small-group learning
Small group problem-based learning has been the core of workshops in EBM conducted in many countries7. In developing countries however, small group learning means an increase in the number of faculty members per student. Again, because of limited resources, this has not been easy to do. Thus, most medical schools stick to standard methods of teaching and passive learning, conducted in large classrooms. As a result, our typical workshop participant is a shy, inhibited individual, unaccustomed to public discussions and spontaneous interactions. Facilitators are problematic as well. Accustomed to giving lectures, they give in easily to prodding by wily participants, and break into elaborate discourses in the middle of what is supposed to be a small group discussion.
In our experience, neither of these problems is insurmountable, and both are worth addressing. Given enough time and exposure, facilitators get the hang of things, spending less time talking and more time encouraging participation. Participants, on the other hand, soon get the idea and join the fray. The result has always been an enjoyable and fruitful interaction. Each session assembles a unique combination of individual personalities, which brings fresh insights into the practice of EBM in developing countries.
It took us a while to venture into small group learning as a tool for teaching EBM, but once we started, there has been no turning back. The feedback has been overwhelming, and requests for workshops lead to many more. In the past 3 years, we have conducted nearly 100 workshops for around 3000 physicians all over the countries. A pool of 50 trained facilitators has grown from the gradual accretion of enthusiastic participants from all over the countries. Few of these facilitators have had any formal training in clinical epidemiology. Most are bright, energetic, young physicians who have just begun their careers and have found great value in their newly acquired skills in practicing EBM.
Lack of time to attend workshops
Time has been a major problem encountered in the conduct of our EBM workshops. Most Filipino physicians receive nothing from their mother institutions. The major source of revenue would be their own private clinics. This means that when physicians are at workshops, they cannot earn their daily wages. As a result, it has been difficult, if not impossible, to conduct 5-day workshops on EBM. Nobody would attend.
Instead, we have modified these workshops into 1 or 2-day affairs, with only the essential ingredients. Critical appraisal is limited to 1 workshop each for diagnosis and treatment. Workshops on causation and prognosis are not given unless specifically requested. These workshops are interspersed with mini-lectures which may include any of the following: 1) a general overview of EBM; 2) obstacles in developing countries; 3) strategies for teaching and applying EBM, and 4) methods for conducting an efficient literature search. When another half-day is possible, some time is spent on critical appraisal of systematic reviews. Participants are also given the opportunity to solve clinical scenarios through hands-on searches, retrieval, appraisal, formulation of a patient-related decision, and finally, preparation and presentation of a critically appraised topic or C.A.T.
For sure, such workshops offer less in terms of content, compared to the standard 5-day workshops. On the other hand, the shortening of the workshop has allowed us to offer it to even the busiest of practicing clinicians.
Lack of role models for practicing EBM
An initial problem in teaching EBM was the lack of role models who could demonstrate various strategies of implementation. As our group of EBM practitioners grew however, several role models emerged. Some practice active EBM in their busy clinical practice, using actual patient problems as stimulus for educational prescriptions and the generation of CATs. A good example would be the experimental EBM service which was recently formed in the Department of Internal Medicine of the Philippine General Hospital. This service attempts to create a model for the practice of EBM in developing countries. Issues unique to developing countries are identified and addressed in this service, providing lots of opportunities for creative thinking and problem solving.
On another front, a group of EBM practitioners have modeled their behavior in a way that is more passive but just as effective. They don't go around lugging computers to their clinics, or preparing CATs to answer urgent clinical questions. They just go about their business, asking the right questions whenever claims are encountered. ("Is that based on an intention-to-treat analysis?") This may be done while attending a lecture in an annual convention, or during encounters with pharmaceutical representatives along the hospital corridor. In our opinion, these questions, raised in public, have had an effect on the quality of information being disseminated. One irate lecturer was overheard saying, "It's getting very difficult to lecture these days; the audiences seem to be asking more difficult questions". Pharmaceutical agents have expressed the same anxiety.
The desperate health situation in developing countries tends to trivialize EBM as just another one of those western innovations - highly advanced, extremely expensive and totally useless. We propose however, that it is exactly this desperate situation, which justifies the need to practice EBM. Several obstacles to teaching and applying EBM in developing countries have been identified. Most of these problems are daunting, but none of them are insurmountable. For the sake of their patients, practitioners in these areas need to come up with their own creative solutions.
Resolution of the scenario
Answers fly by your consciousness, and time seems to come to a standstill. As the tension mounts, you gather all your resources, and draw on your extensive experience as an EBM facilitator. You exert great effort to shed your usual role as lecturer. You muster all your self-control, and with great courage you reply. "So..., what do you think?".
- Dans AL et al. A review of the practice of executive check-ups in 9 Metro Manila hospitals from January to December 1996. (unpublished)
- Dans AL. The value of exercise testing in screening for asymptomatic coronary artery disease. Phil J Cardiol, 1991; 20(1):609-617.
- ISIP Study Group. Acute myocardial infarction in tertiary centres in Metro Manila: in-hospital survival and physician's practices. (In Press. Asean Heart J).
- Sison J et al. Prevalence of hypertension among Filipinos (unpublished).
- Dans AL, Dans LF Guyatt et al. User's guide to the medical literature xiv: how to decide on the applicability of clinical trial results to your patient. JAMA 1998; 279(7):545-549.
- Glasziou PP, Guyatt GH, Dans AL et al. Applying the results of trials and systematic reviews to individual patients. Am Coll Phys J Club 1999;
- Sackett DL, Richardson WS, Rosnburg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. Churchill Livingstone, 1997.