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When expertise plus evidence-based medicine isn’t enough, will implementation science get us to the finish line?

Open AccessPublished:April 01, 2022DOI:https://doi.org/10.1016/j.xfre.2022.03.005
      Evidence-based medicine (EBM) is a term coined by Gordon Guyatt, Professor of Clinical Epidemiology and Biostatistics, McMaster University, in 1991 to describe a movement that had been building in the previous decades away from expert opinion and toward a more structured epistemological approach to evaluating, grading, and applying empirical evidence to the clinical practice of medicine (
      • Djulbegovic B.
      • Guyatt G.H.
      Progress in evidence-based medicine: a quarter century on.
      ). Over the 3 decades since its official birth, EBM has faced its share of criticism from scientists and clinicians for being overly prescriptive, inappropriately hierarchical, and out of touch with individual patient needs. Nevertheless, thanks to a solid foundation and evolution and maturation over the years, it has become a core component of undergraduate and graduate medical education and has led to a shared language in the scientific literature.
      An international group of experts in polycystic ovary syndrome (PCOS) met 20 times over 15 months leading up to 2018 to consider the available data on PCOS, rate the strength of the science, and develop clinical guidelines for the diagnosis, management of symptoms, and screening for long-term morbidities. These guidelines were ultimately published in several journals in 2018 (
      • Teede H.J.
      • Misso M.L.
      • Costello M.F.
      • Dokras A.
      • Laven J.
      • Moran L.
      • et al.
      Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome.
      ). The experts used Appraisal of Guidelines for Research and Evaluation II-compliant processes and the Grading of Recommendations, Assessment, Development, and Evaluation framework, following best evidence-based medicine practices. Indeed, this publication is the first thing listed in PubMed when one searches for “evidence-based medicine and gynecology.”
      Despite this herculean accomplishment, the authors of “Implementation of International Guidelines for Polycystic Ovary Syndrome: Barriers and Facilitators Among Gynecologists and Primary Care Providers” in this issue of F&S Reports identified in their study a lack of awareness and implementation of these guidelines in a group of primary care providers and general gynecologists interviewed in the months after the publication of the guideline (

      Lee ITL, Sansone S, Irfan M, Copp T, Beidas R, Dokras A. Implementation of international guidelines for polycystic ovary syndrome: barriers and facilitators among gynecologists and primary care providers. FS Rep. In press.

      ). This was a qualitative, thematic analysis of interviews with a small number of physicians from one academic medical center; nevertheless, the results are consistent with others, suggesting that lack of time and knowledge are barriers to incorporating the new best clinical practices into patient care. As one of the named experts and authors of the 2018 international guidelines, the senior author of this interview study must be greatly concerned with the lack of implementation of these guidelines.
      In their discussion, the authors encourage a multidisciplinary approach to manage PCOS, as also recommended in the international guidelines, to capitalize on the strengths and focus of different specialties. They also suggest that it is time for the next stage of research to draw on principles of implementation science (

      Lee ITL, Sansone S, Irfan M, Copp T, Beidas R, Dokras A. Implementation of international guidelines for polycystic ovary syndrome: barriers and facilitators among gynecologists and primary care providers. FS Rep. In press.

      ). Implementation science is a relatively new branch of biomedical inquiry that aims to improve the uptake of evidence-based medical practices to optimize patient and community impact and facilitate policy development. In fact, the authors’ own work here using qualitative methods to identify specific facilitators and barriers to the utilization of these guidelines can be considered the first step in implementation science.
      In 1995, Dr. David Grimes, an early adopter and prolific educator of EBM in obstetrics and gynecology, wrote, “No human endeavor relies more heavily on information than does the practice of medicine, yet few others manage data so clumsily… Regrettably, the daily practice of medicine lags far behind what we know (
      • Grimes D.A.
      Introducing evidence-based medicine into a department of obstetrics and gynecology.
      ).” Although EBM has since established a foothold in medicine, albeit incompletely, implementation science must also now be embraced and expanded in our field to close the “know-do” gap identified by Dr. Grimes. This cannot be done by biomedical researchers and clinicians alone but requires transdisciplinary collaboration to identify barriers, match these with effective implementation strategies, and see these to the finish line.

      References

        • Djulbegovic B.
        • Guyatt G.H.
        Progress in evidence-based medicine: a quarter century on.
        Lancet. 2017; 390: 415-423
        • Teede H.J.
        • Misso M.L.
        • Costello M.F.
        • Dokras A.
        • Laven J.
        • Moran L.
        • et al.
        Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome.
        Fertil Steril. 2018; 110: 364-379
      1. Lee ITL, Sansone S, Irfan M, Copp T, Beidas R, Dokras A. Implementation of international guidelines for polycystic ovary syndrome: barriers and facilitators among gynecologists and primary care providers. FS Rep. In press.

        • Grimes D.A.
        Introducing evidence-based medicine into a department of obstetrics and gynecology.
        Obstet Gynecol. 1995; 86: 451-457

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