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British Medical Bulletin 69:179-196 (2004)
British Medical Bulletin, Vol. 69 © The British Council 2004; all rights reserved

Evidence-based medicine: a new ritual in medical teaching

Simon Sinclair

School for Health, University of Durham, Stockton-on-Tees, UK

Correspondence to: Simon Sinclair, School for Health, University of Durham, Queen’s Campus, Stockton-on-Tees TS17 6BH, UK


   Abstract
Top
 Abstract
Introduction
 The EBM meeting: account
 The EBM meeting: analysis
 Conclusion
 Acknowledgements
 References
 
Western medicine is a diverse social and cultural system which responds in different ways to internal and external pressures. The Evidence-Based Medicine (EBM) movement has, despite some resistance from the rofession, led to the introduction of EBM into many areas of medicine, including medical training. Using material from teaching sessions for junior psychiatrists in England, I argue that EBM’s novelty and potential challenge to established medical practice has been absorbed and accommodated within ordinary professional life by ritualizing EBM teaching in the familiar form of a traditional teaching ward round, with the difference that a published paper is ‘presented’ rather than a patient. These ritual occasions have the further effects of preventing any debate about EBM (partly because of the lack of immediate clinical application) and of limiting thought outside the paradigm of EBM and, indeed, of Western medicine itself.


   Introduction
Top
 Abstract
 Introduction
The EBM meeting: account
 The EBM meeting: analysis
 Conclusion
 Acknowledgements
 References
 
The understanding of Western medicine as a varied and changing social and cultural system is well-established. A relatively recent development within this culture is the introduction of Evidence-Based Medicine (EBM) to medical training and practice. The ‘evidence’ is to be found in papers published in academic journals (previously known as the ‘literature’); such papers report scientific clinical research conducted on groups of people, with statistically analysed and authorized results.

Although traditional medical practice is also based on the findings of science (itself a particular social and cultural system), it has traditionally been taught to students and junior doctors in relation to the treatment of the individual patient. To such an individualistic approach, EBM, with its basis in clinical epidemiology, clearly poses both theoretical and practical problems; such problems, which are by no means new ones, concern the relationship between the general and the particular (the equivalent problem for anthropologists is the debate about the nomothetic or idiographic nature of their discipline).

For doctors, incorporation of EBM into everyday clinical practice—the introduction of EBM was intended to aid, rather than supplant, personal clinical experience—obviously involves a major change in the practitioner’s approach. More specifically, EBM ("the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients"1) involves asking and answering many questions: What is the question about this patient that both needs an answer and can be answered? Where is the evidence that might answer that question? When critically appraised, how good is that evidence? Should it be used? If it was used, did it help?

It is, at first sight, perhaps difficult to see how anyone could argue with this approach, with its radical but rational attempt to link published research to clinical practice. Certainly for doctors, the practical idealism of EBM might seem to coincide perfectly with their own2. And, indeed, at the end of the last century in the UK, in a social context that included a rather beleaguered medical profession and successive governments insistent on reform of the National Health Service (NHS), EBM was swiftly taken up wholesale by the official representatives of the profession, by government and by NHS Trusts, and has become firmly placed in both undergraduate and postgraduate medical training.

The Royal College of Psychiatristsa, for example, introduced the completely new Critical Appraisal paper to the Membership Examination (the MRCPsych Exam) in 1999, with the requirement that psychiatric training schemes (which have posts for junior doctors approved by the College as training posts in psychiatry) hold frequent—approximately 30 a year—and regular ‘in-house’ teaching sessions which trainee psychiatrists should attend. These should comprise both clinical Case Conferences and Journal Clubs, to teach the principles of EBM and to provide training in critical appraisal for the MRCPsych Exam. As a consequence, all sorts of events and publications (courses, books, manuals) have been developed to meet the need of psychiatric trainees to pass this particular part of the MRCPsych Exam; only by passing the MRCPsych Exam are the upper reaches of a career in psychiatry open.

But there has also been considerable resistance within the medical profession to the EBM movement, viewed by some—only half-humorously—as a quasi-religious cult3. Novelty on its own (and the necessity of using electronic technology) may be thought to be something of a problem for what is regarded in some respects as a conservative profession. As Pope4 describes, EBM does not easily accommodate other sorts of evidence and, in particular, challenges doctors’ personal practical experience and knowledge, as well as traditional, status-related "eminence-based medicine"5; the evidence itself may be doubted as being sufficiently ‘practice-based’ in real clinical situations.

Further, the nature of the evidence is epidemiological and involves the use of statistics. For example, as regards any clinical intervention, the highest level of research evidence, the ‘gold standard’, is the Randomised Controlled Trial (RCT) which can only be assessed statistically. Not only was clinical epidemiology a culturally low status branch of medicine6 but statistics deals in probability rather than the certainty that is generally looked for and provided in medical training7. As well as these obstacles to the straightforward diffusion of EBM, some doctors are also suspicious of the way EBM may be used by managers and others to increase their control and limit doctors’ independence8.

In this paper, I try to show how, despite the professional reservations noted above, the requirement for EBM teaching in psychiatric training has been incorporated into the ordinary life of both junior and senior psychiatrists with whom I work. The paper is based on my attendance at various sorts of meetings, in Academic Departments of Psychiatry, academic seminars elsewhere, and at management meetings. But it is principally based upon my observations of the weekly teaching sessions (of a clinical Case Conference followed by a Journal Club) for junior doctors held at a local hospital.

As an anthropologist as well as a psychiatrist, I became interested in the way the Journal Clubs (but not the Case Conferences) had changed about 2 years ago; the format became more rigid and, because more rigid, more repetitive, and therefore more striking. I originally started making informal notes during these sessions in 2002; in such a setting, writing is not difficult and I had had experience of this sort of participant observation (both taking part in medical teaching sessions and recording them) during previous fieldwork. Again, though I caused little or no disturbance or intrusion, I was occasionally asked what I was doing and I explained the outlines of a possible anthropological research project. When it became clear that this paper might indeed be written, I asked—in accordance with the Ethical Guidelines for Good Research Practice of the Association of Social Anthropologists of the UK and the Commonwealth—those doctors attending the sessions for their permission to continue to take notes during these sessions, with a view to publishing a paper. Given my undertaking to preserve privacy and ensure anonymity to the best of my ability—the question of confidentiality hardly arises in this context—this permission was granted in return for my future presentation of the completed paper to the group. I should say that my attendance at the teaching sessions was diligent but not exhaustive and my notes not entirely systematic: because of the format of the Journal Clubs described below, after a while I only recorded what seemed to me to be particularly illustrative examplesb.


   The EBM meeting: account
Top
 Abstract
 Introduction
 The EBM meeting: account
The EBM meeting: analysis
 Conclusion
 Acknowledgements
 References
 
The two hours of the Case Conference and Journal Club are locally known as ‘academic’ sessions. This time is sometimes used for other training purposes (such as training in Interview Skills), while the room is also used, at other times, for other sorts of meetings (such as appointment interviews and management meetings). It is equipped with screens at one end, both for projection from acetate overheads and from PowerPoint, and for writing on, and this end of the room forms its focus. The chairs, though, are by no means all arranged facing towards this end (with some placed against the walls facing inwards and others round the central table, and therefore facing away from the screens). Some, apparently rather grudging, movement of chairs is made to make them face in the rough direction of the screen before the meeting starts. This arrangement is in rather obvious contrast with management meetings round a table, whereas the chairs in the Academic Department are precisely ordered in rows to face the front.

All junior psychiatrists in training posts are required to attend these weekly academic meetings as part of their training, as audience, and every such doctor, with varying degrees of help from their consultant, is obliged in rotation to take the stage and present a patient and a paper published in an academic psychiatric journal—private study for the exam is insufficient. The only times when this obligation is waived is when the junior doctor is unexpectedly away; anticipated holidays, for example, lead to an exchange of dates with another. Consultants are present (their own requirements now include attendance at a given number of academic sessions for the purposes of Continuing Medical Education and, in the future, revalidation with the General Medical Councilc) and there may also be medical students present. A sheet of paper for doctors to record their attendance is usually passed round. Nurses are asked not to summon doctors by bleep or mobile telephone during these two hours. The setting and the people involved make these regular events unusual in the context of the rest of the working week; then, time is spent on the wards, in clinics and clinical meetings, and in other activities contingent on clinical practice, in company with nurses, social workers, managers and others (but with only one or two other doctors), dealing with the relatively unpredictable and messy world of clinical work dealing with individual patients.

The academic meeting starts informally with doctors helping themselves to tea and coffee from the trolley and talking among themselves but is usually called to order within five or ten minutes of the official starting time. During the first hour (of the Case Conference) a junior doctor, with a varying degree of sponsorship from the consultant they work with, ‘presents’ a particular patient in the conventional, stylized way with its stagey and dramatic elements9–11. The orally given conventional history (created from the answers to a set of questions asked of the patient) is reflected in a written summary of the account shown on the screen, but the history could be given without this. A video recording made of the patient being interviewed may be shown and, sometimes, the patient agrees to attend in person to be interviewed and to answer questions from the assembled doctors. Questions are then put by the consultants to the presenting doctor and to other junior doctors, first about the diagnosis and then the clinical management. There then follows a more general discussion, when questions of diagnosis and management may be hotly disputed by consultants.

The Journal Club (which I shall call ‘the EBM meeting’) takes up the second hour. This is devoted to the presentation by the same junior doctor of a published paper which deals with some matter related to the clinical case just presented. The paper for discussion has usually been circulated beforehand, though it has by no means always been read, and the experienced presenter leaves a pile of photocopied papers on the desk for those who have forgotten to bring theirs. So the junior doctor again stands or sits by the side of the desk, again controlling ‘the visuals’, and begins another, similar, stylized dramatic performance of presenting the paper orally. A visual replication of the spoken account is again shown on the screen but now, partly because of the lack of narrative in this part of the presentation, the presenter finds it almost impossible to proceed without this visual aspect. On one occasion, when the PowerPoint projection system failed to work, the presenter began by saying [books on critical appraisal recommend that a ‘take home message’ ends the appraisal], "The take-home message, before we start, is ‘Always have your [visual] presentation available in more than one medium’ [i.e. on overheads as well as on PowerPoint]!" But only when the electronic system was working did he start.

There is sometimes a brief introductory statement about how this particular paper was chosen for presentation. It may have been chosen because it was topical or recently published; sometimes the presenter has taken the first step in EBM outlined above, that of formulating a clinical question and of searching the literature. If this first step has been taken, and described (for example, the problem of preventing relapse in Bipolar Affective Disorder and what psychotropic medication might be used to this end), it is often followed by a statement that a very large number of papers dealing with this combination of elements was found and, even by refining the question, the number of papers was still far beyond the time and capacity of the presenter to analyse. This may be confirmed by a consultant: "I think we all know the problem [doctor’s name] described: you put in [to the computer database] Bipolar Disorder, elderly [patients] and treatment and get 10,000 papers. I tried to do a search as well and came up with the same thing." Conversely, a statement may be made to the effect that, "There aren’t a lot of papers on this subject, as we discovered." More usually, the presenter starts by describing the paper in outline, its aims, methods and conclusions; the summarized conclusions often finish with the presenter stating something along the lines of: "The authors end by saying there is a need for more research".

The main part of the presentation, the critical appraisal of the paper, follows. This takes the form of running through a series of questions, taken from one of the many handbooks (or photocopied handouts) available for this, which are sometimes referred to by name; this spoken account is accompanied by projections onto the screen, often of the list of questions themselves. The presentation, then, does not include the later steps of the EBM process of deciding whether the evidence discussed does have a precise clinical application but is confined to the aspects of EBM that will be tested in the MRCPsych Exam, i.e. the critical appraisal of the evidence provided by a given paper.

In general, these serial questions are designed to establish whether the design and methods of the research meet standards that allow its conclusions properly to be made, and therefore whether there are indications of any sort of bias in the study (the possibilities of systematic bias in RCTs, for example, include selection, performance, exclusion and detection bias). The presenter may simply answer the recommended serial questions: "The [research] question is well-defined but could not be used for a systematic review" or may ask the questions out loud before answering them, in this instance almost contemptuously:

"Was [sic] the inclusion and exclusion criteria mentioned? No.

"Was the search strategy stated? No.

"Was the validity of the studies included assessed? No.

"Was an estimate of the effect of each subgroup studied summarized? No.

"Was the review up to date? The relevant cut-off date wasn’t stated."

Equally, as advised, indications that the researchers had got some things right are included: "Good points: there were well-defined aims; it was an appropriate design for this sort of data; there was a decent period of follow-up, over 12 months; in the discussion, they were careful not to jump to conclusions". One presenter said: "Another good point is that it [the paper] does include non-pharmacological treatment". This may be taken as a reference to the fact that a proportion of papers presented about treatment deal with the effect of psychotropic drugs, and that such research may be funded by drug companies who have a vested interest in publishing studies with a particular conclusion (another form of bias, known as publication bias).

Comments about the statistical methods used in the research may also be made by the presenter: "As the statistics are relatively easy, I thought I’d explain them—otherwise I couldn’t!" Sometimes the comments are sharper: "That [analysis of variance] is a more complex mathematical procedure usually done by computers and nobody really understands it apart from mathematicians who use mathematical jiggery-pokery!" The use of statistics to blind the reader may also be referred to: "If there is unclear and unexplained mathematical analysis which you’ve never heard of, the paper is probably rather fishy." Statistical methods may indeed be the vehicle for forming some kind of alliance between junior doctors and consultants: "Incidentally, I’ve no idea what Table 3 means—when I asked my consultant and she didn’t know either, I felt less stupid."

During this part of the EBM meeting, doctors sit around, with varying degrees of attentiveness and interest in the proceedings. Some are clearly engaged in the presentation, even if they are re-reading (or reading) the paper through themselves; others are not—dozing is possible. At the end of the presentation, one of the presiding consultants then asks if there are any questions that the junior doctors want to ask the presenter. Now the junior doctors, in the past, made a collective decision not to offer any questions at this point in the EBM meetings; this convention has been maintained, even though the membership of the group has changed more than once. The resulting silence ends with a consultant asking an individual junior doctor by name for a question, or a comment implying a question, about the paper or the presentation. The junior doctors usually have this ready: "It’s not really clear what they [the researchers] did in their follow up and also was it 100% follow up? There’s no drop-out rate mentioned"; "They haven’t matched for severity of illness, which is obviously going to affect prognosis".

The other consultants are then invited to make comments along the same lines, which they do: "[Matching groups like that] sounds like a post hoc analysis"; "I think that [the exclusion of the terminally ill] seems very appropriate"; "I would say that [assumption] is logically flawed: if you assume it’s under-reported, then you would over-estimate the effect". These comments gradually merge into more summary statements by consultants, which may include ‘take home messages’: "In some respects the recommendations come across with a greater degree of authority than perhaps is warranted"; "You need a study of this sort of size to have any chance of finding out a factor with a result like this. You can’t be sure there isn’t another variable which confounds these results—we can never be sure—but this seems to be a pretty powerful study"; "This isn’t going to make any difference to teenagers". These statements include questions that the paper presented does not answer: "What would be interesting would be to get similar figures for women—there’s not supposed to be any difference in lifetime incidence [of schizophrenia]".

Other sorts of bias in the paper may be alluded to. Towards the end of one discussion, a consultant speculated whether the paper under discussion was published "as the result of making a [business] case for establishing a Delirium Ward". Comments may also be made about the use of EBM by managers for their own ends: "That’s the management stance: if there isn’t an ideal RCT out there, there isn’t any evidence". These summary statements often include comments about the shortcomings of the evidence base itself: "It [the paper] has got lots of flaws and every paper we look at has lots of flaws but it does make you think about the longer term, beyond the episode itself [requiring hospital admission]"; "It [the paper] highlights the issue of paucity of research in a significant section of the population"; "You can’t automatically assume that transfer [of the results of this paper] to Older Age patients is appropriate. If you get an RCT, it tends to be the fit elderly [that are studied]. There are huge gaps in the evidence base related to psychiatric treatment in the older population". But the principles too are repeated: "You take the best available external evidence, which leaves much to be desired in EBM terms, and combine that with your clinical practice".


   The EBM meeting: analysis
Top
 Abstract
 Introduction
 The EBM meeting: account
 The EBM meeting: analysis
Conclusion
 Acknowledgements
 References
 
The view might be taken that these EBM meetings are no more than technical pedagogic exercises to ensure that junior doctors have the skills to pass the MRCPsych Exam, with the final aim of improving their ability to match their patients with the best treatment known; this view is, in effect, that of the Royal College of Psychiatrists12. The speed with which such a new element to academic meetings has been introduced certainly indicates the power of the College to determine the frequency of these events, principally by incorporating examination of some EBM techniques into the MRCPsych Exam and stating that a failure to hold these meetings would result in the withdrawal of approval for the training scheme (and therefore the absence of aspiring junior doctors applying to join the training scheme, something no consultant could countenance). But this view does not explain how this entirely new aspect of training has been so thoroughly assimilated into professional activity, given the disagreement in the profession about EBM.

A new ritual

The old anthropological approach to ritual relied upon a distinction between two kinds of action: that, on the one hand, which was ends- directed and reasonable from the anthropologist’s point of view—and which might be described as related to skill, technique or craft—and, on the other, action which was apparently irrational and, as far as the anthropologist was concerned, did not reveal any such links. Only the second kind of action was to be thought of as ritual. With the difficulties of ascertaining people’s own motives for their actions and their own understanding of the results, and of trying to determine what was (from an outsider’s point of view) reasonable, Lewis13 considers that this view of ritual implies that the anthropologist has to make an unwarranted assumption and therefore a wrong conclusion: "if an activity is clearly practical and effective, that it cannot be ritual. This may blind us to the possibility that an action may have both aspects."

Whereas anthropology originally developed most of its theory from studying what were thought of as traditional societies, the fascination with irrationality tended to focus on magico-religious ‘ritual’; this attention, combined with the later use of ‘ritual’ to classify some activities in contemporary secular settings, created an almost meaningless anthropological term14. In the face of this, Bell15 proposed an alternative approach. Rather than trying to refine the definition of ‘ritual’, she suggested that activities themselves could be operationally defined as ‘ritualized’.

There can be no doubt, I think, that the activities involved in presenting a paper in EBM meetings have become, in Bell’s term, ‘ritualized’. That is to say, these activities are set apart from their context of everyday psychiatric practice both by their unique combination of setting and audience, and by other differentiating features: those of order, repetition, the dramatic form of presentation and the staging of the event, the use of special terminology, with definite social and collective meanings16. These features are obviously present in other academic situations but the atmosphere of EBM meetings, where the institution prescribes a formal dissection of others’ work, is clearly very different from the "seminar culture" described by Gell17. In his admittedly idealized description, the weekly departmental seminar is "a social occasion, a game, an exchange, an ordeal, an initiation". Papers are presented by their authors, who may have written them expressly for the seminar rather than for publication, and who are then questioned by the audience. The skilled presenter "relishes the cut and thrust of debate, and exploits the opportunity afforded by hostile questioning [by all members of the audience] to produce additional extemporized displays of wit, turning the questions back on the questioner and making fun of their positions". These more personally dramatic performances are not only intellectually exciting but also constitutive of departmental solidarity, ending rather than beginning with informal discussion.

The novelty of EBM meetings as ritualized practices indicates that, in some ways, a tradition has been invented18 and, indeed, one junior doctor referred to the "traditional hierarchy of evidence", with RCTs at the top. This new tradition looks as much to the future as to the past, a temporal perspective that indicates that EBM meetings are not only technical and pedagogic exercises but also incorporate symbolic and ideological elements; these are, simply put, the idealism of doctors applying reason to written evidence for the purposes of the future betterment of patients. Another way of thinking of this is in terms of the interplay between the embodied medical dispositions of Idealism, Status and Knowledge, which, with other dispositions, make up the medical "habitus"19 (the habitus is the collectively created but individually expressed outlook and action of any particular group, here of doctors). This approach to understanding the constitution of doctors relies heavily on Bourdieu’s notion of embodied dispositions and, with it, the production of a "ritualized body", with a "sense" of ritual and, ultimately, of "ritual mastery"20. How, then, does this new ritualized activity, that of the EBM meeting, fit into doctors’ pre-existing medical habitus?

A familiar setting

The setting, the audience and the other features noted in EBM meetings are found in other "official front-stage" medical activities21, such as ward rounds and lectures. Indeed, the first part of the academic meeting, the clinical presentation, is in principle (apart from the use of the screen, which is not essential) no different from the presentation of a patient by a junior doctor at a teaching ward round; there the practical clinical dispositions of Experience and Responsibility are taught by the questioning of junior by senior doctors. Experience may be thought of as the personally acquired capacity to appreciate the medical implications (particularly as regards diagnosis) of a patient’s presentation, and Responsibility the personal exercise of medical action taken towards the patient. These dispositions roughly correspond to the composite notions of individual "clinical expertise" and "clinical judgement" which are described by many commentators on the practice of medicine as characteristic of the medical mentality22,23; doctors therefore having certain, individual and idiosyncratic "quasi-normative"24 views, the arguments between consultants described at the end of the Case Conference (when the session goes some way towards Gell’s ideal) are hardly surprising. With the change of the subject of discussion from a patient to a written paper, the same stage becomes the setting for the learning and teaching of the medical disposition of what I have called Knowledge (the public revelation of scientific, objective fact about the natural world, conveyed through writing—and speech closely connected to writing—and images), which involves a kind of knowledge quite different from that found in the dispositions of Experience and Responsibility23,25.

The problem of certainty

The Knowledge taught and learnt earlier in medical training (for example, in Anatomy lectures) is, I have suggested, like Experience and Responsibility, distinguished by its epistemological certainty26. And this certainty continues to be found in text-books and in the lectures given in the MRCPsych Course at the Academic Department of Psychiatry, where junior doctors are told the facts (which may be statistical facts, such as the lifetime incidence of schizophrenia) that they need to know about the nature of psychiatric diagnoses and their treatment; their possession of this Knowledge will again be tested in the MRCPsych Exam by Multiple Choice Questionnaires, in which there are, of course, right and wrong answers.

I have also indicated that some preclinical disciplines (such as Psychology and Sociology) are less inclined to supply reproducible and certain facts and are therefore thought, by most medical students, not to be proper medical subjects. Above all, Statistics (and, by extension, Epidemiology) with its language typified by lay words given scientific meanings and relating to numerical concepts about groups (rather than languages that use special scientific words relating directly to things) and its emphasis on degrees of probability rather than on certainty, is not only set apart from other preclinical disciplines but also defined as almost non-medical27. There therefore appears to be a further problem: as regards EBM, how can the certainty of Knowledge be upheld in the probabilistic world of statistics, apparently still so uncongenial for most doctors as for most medical students?

As the books on critical appraisal indicate, there is a set of questions to be asked about any paper, depending on its nature (for example, whether it is an RCT, a cohort study or a case–control study). These questions are phrased in similar ways in books and handouts. There is therefore no doubt about the precise questions to be asked of any given paper; such questions themselves can therefore be thought of—without doing too much violence to these statistical terms—as both reliable (that is, repeatably accurate) and valid (that is, testing what they are supposed to test). The cross-examination in the EBM meeting (and, ultimately, the MRCPsych Exam) will establish both whether the junior doctor knows what questions to ask to determine whether there are any flaws in the proposed Knowledge, and if there are any such flaws—it is possible to score full marks (20/20) on the Critical Appraisal paper in the MRCPsych Exam. To this extent, then, there is certainty to be found in the EBM meeting, a matter I shall return to later.

Questioning and power

I have indicated elsewhere the importance of questioning in basic medical training—the student asks the patient questions and is then questioned by the doctor on the nature and results of these questions—which I have suggested is central to the formation of the basic medical habitus28. Now, nearly all papers presented in EBM meetings can be thought of as the published results of questions asked by the researchers of patients, in one way or another; the junior doctor then publicly asks the routine relevant series of questions of the paper (much as there is a set of relevant questions to be asked of a patient who is, say, short of breath) and is then publicly questioned on the nature and results of her own questions by those senior to her. So any junior doctor, already familiar with a pre-existing pattern of Question and Answer, with questioning determined by the Status of the questioner and the knowability of the answers, will find no difficulty in incorporating this new series of questions into her person; she now learns to question herself about the questions she should ask about the questions the researchers have asked, as well as learning to answer questions asked by others (orally in EBM meetings by consultants, in writing in the MRCPsych Exam by the examiners).

There are therefore some aspects of EBM meetings that are very familiar to all doctors: the staged setting, the public presentation to an audience, the certain nature of the questions to be asked and the pattern of Question and Answer. The power relations in EBM meetings are also familiar. Doctors are used to the canons of behaviour in ward rounds and the junior doctors’ collective view about not questioning each other publicly may be thought of as congruent with medical students’ approach in teaching ward rounds. In that setting, questioning one of their colleagues, instead of leaving the questions to the doctor, is despised as a Competitive disruption to their general Co-operation. Junior doctors’ reluctance to put questions may also be thought of as the equivalent of medical students not "volunteering" information29. So junior doctors recreate a familiar horizontal disposition of Co-operation within their group and, thereby, a familiar recognition of vertical medical Status. The individual doctor presenting the paper will have had some guidance from her consultant, again creating a variable horizontal relationship. But consultants too are bound—up to a point—by their own regulations to attend EBM meetings. Some consultants may be even less proficient in EBM methods than their juniors, having passed the MRCPsych Exam before the Critical Appraisal Paper was added to it, and may, to this degree, function at the same level as their juniors. And the typical absence of any of the intermediate grade of psychiatrists (Specialist Registrars) among this group of doctors, away from the Academic Department, also lessens the impact of the hierarchy. For, while EBM meetings provide a stage for doctors to develop their mastery of the ritual of EBM and, for some, thereby to authorise their position both locally and within the College’s own systems, there are not enough ritual masters in this peripheral situation to lead to the dramatic inter-personal conflicts of what has been called "ego-based medicine", occasionally found in EBM meetings in the Academic Department. There is almost no outright disagreement among consultants: the questions remain unquestionable and no argument is provoked.

Here, then, there are familiar power relations constructed, with vertical degrees of ritual mastery interacting with the official levels of the medical hierarchy and, horizontally, a sense of solidarity among all those who, with varying amounts of enthusiastic professional Idealism30, take part in EBM meetings. And, while simply attending EBM meetings implies some acquiescence, there is no total social control in the sense of a required acceptance of the practice or the principles of EBM. Resistance here is possible, though usually unspoken. But it is still the junior doctor who has to prepare the presentation, stand up in front of the screen and answer questions. The business of who questions whom is dependent, once again, on Status. At the same time as the nature of proper medical Knowledge is confirmed, so is junior doctors’ place within the hierarchy.

The answer to the question of how the novelty and potential challenge of EBM has been accommodated into professional activity is therefore simple: EBM meetings have, in their ritualized form, adopted, with some minor thematic variations, the very familiar traditional form of teaching ward rounds; the only major difference is that a published study and not a patient is presented. This familiarity calls upon previously learnt medical dispositions, leading to the easy assimilation of the practices of EBM meetings (though not to their application in clinical practice) and to the formation of a more developed medical habitus, just as presenting patients contributed to the creation of these doctors earlier in their training31.

Other implications of ritualization

While the need for certainty has been met by the formulaic series of questions to be asked, the ritual aspect of EBM meetings holds other implications. As I hope I have indicated, EBM meetings are not very intense occasions (except perhaps for the novice presenter); they are certainly less so than teaching ward rounds where students and junior doctors have considerable emotional investment in not being shown up as ignorant or uncaring. Nevertheless, they are professionally required and relatively absorbing theatrical events that, at the same time, attract participants’ attention and distract them from looking outside the ‘frame’.

For example, the definition of a patient’s problem (one of the first steps in EBM) will be couched in terms of a diagnosis or ‘target disorder’. The creation of evidence will necessarily have involved the use of some sort of measure or ‘instrument’ to indicate the presence or absence of such a disease or disorder, and one of the important steps in critical appraisal is assessing the validity of this instrument: "Does the instrument actually measure what it is supposed to?" is one of the questions to be asked. The concept of validity is glossed in one handout as "Closeness to the Truth". There is a set of concepts (including those of sensitivity, specificity and accuracy) which are employed statistically to establish how far such diagnostic or screening instruments approximate to another ‘gold standard’, at which an instrument would identify every patient with the diagnosis or condition and not include anyone who did not. The implications are clear: whereas human researchers may introduce bias of many sorts into their studies, diagnoses or disorders reflect natural, not man-made, realityd.

As well as the question of validity, there are many other questions to be asked in assessing the methodological soundness of any paper and the justification of its conclusions. The fact that, after proper questioning, there nearly always are flaws to be found (and, if not, that there remain questions unanswered in the paper) also demonstrates the reverse: there is somewhere and somehow a way of producing research findings that are incontestably true (or, more strictly, that only have a vanishingly small chance of being false). At the same time as casting doubt on any given paper, then, the certified and relentless questioning continues to raise the possibility of absolute certainty, that there is, or was, a way of finding verified truth.

Ritual activity creates (and, it must be stressed, does not reflect) what Bloch32 calls an "alter-cosmogonic" view of a "purer, more ordered, order"—for those alert and interested in EBM meetings, the view is offered that the ideal research study can in fact be done, free from any kind of bias as regards funding or wider political purpose, and from methodological bias (and so with properly randomized groups, accurately representing categories of real patient populations who are blind to the different treatments they are given by researchers, also blind to the treatments they provide), in sufficient numbers to make the study statistically powerful enough to justify definite conclusions, which can then be acted on by doctors without political or financial constraint. The scientific truth is out there, somewhere, and might, somehow, be found; more research is needed.

And this view is strengthened by the language, with its internally consistent, impersonally scientific and explicitly rational terms, in which the questions and answers are phrased. Such a language constitutes a form of rhetoric in itself33; it is also to be seen as deriving from a higher authority, and used by practitioners as delegates34. So not only does the ritualized use of language prevent other linguistic approaches being used, but the very terms found in statistics, taken from lay language and scientifically redefined, are only available in this context in their scientific sense: so, the words ‘power’, ‘bias’, ‘validity’, ‘accuracy’, ‘sensitivity’ and ‘truth’ itself have in this context only statistical meanings.

In the form of presentation in EBM meetings, then, the medium—of an orderly series of logical questions openly put about the paper—is the message; the ritualized activity is simultaneously a declaration about ideal medical practice and a demonstration of (or at any rate part of) its operation. But this logical questioning cannot itself be questioned in EBM meetings. As Bell puts it, ritualization is a "particularly ‘mute’ form of activity. It is designed to do what it does without bringing what it is doing across the threshold of discourse or systematic thinking"35. So, at the same time as keeping the possibility of an unbiased, flawless trial alive in doctors’ minds, and no doubt as a consequence of it, the prescribed form and nature of the questions in EBM meetings prevent a more fundamental questioning of the categories, basic practices and "tenacious assumptions" of Western medicine36, those of naturalism, individualism and freedom from morality, as well as of the political implications of numbering and recording37,38. "Through form and formality it [collective ceremony] ... banishes from consideration the basic questions raised by the made-upness of culture, its malleability and alterability"39.


   Conclusion
Top
 Abstract
 Introduction
 The EBM meeting: account
 The EBM meeting: analysis
 Conclusion
Acknowledgements
 References
 
EBM, in the form of EBM meetings, has been easily accommodated into the training activities of this segment of the medical profession by a process of ritualization that employs pre-existing medical dispositions in the traditional form of the teaching ward round. The certainty of Knowledge is maintained by the required nature of the questions to be put and by the assumption of the existence of external truth awaiting its demonstration in a flawless piece of research.

The absence in EBM meetings of the requirement of definite and particular clinical application leads to the "implementation gap"8. The evidence in EBM meetings remains "trial data" and is not converted into "practical knowledge"40; in terms of medical dispositions, it remains external Knowledge and is not assimilated into personal Responsibility. For this to happen, chance—or her scientific sister probability—rather than certainty would (through some EBM process or other, such as the Odds Ratio or the Number Needed To Treat) enter undisguised into individual clinical practice. Any such bedside epidemiology would indeed be a radical departure from traditional practice and was no doubt originally intended to be so.

The detachment of EBM teaching from clinical practice has the additional effect of preventing questions about the precise clinical implications and practice of EBM, and (I have suggested) about Western medicine itself. Even despite this, there are real doubts about the practical value of EBM, though junior psychiatrists may of course pass the Critical Appraisal paper of the MRCPsych Exam. There does not appear to be any good evidence, in EBM terms, that teaching EBM changes either individual clinical practice or patient outcomes for the better, though this is doubtless a difficult area for research. It is therefore likely that, unless the effects of EBM teaching are assessed as part of a clinical rather than a written exam (so insisting that such Knowledge contributes to Responsible medical action), this new ritualized medical activity may continue to be something of an academic ritual, in the pejorative sense of ‘academic’ and in the old anthropological sense of ‘ritual’.


   Acknowledgements
Top
 Abstract
 Introduction
 The EBM meeting: account
 The EBM meeting: analysis
 Conclusion
 Acknowledgements
References
 
I am most grateful to my colleagues for their permission to complete and publish this research. I am also very grateful to Clive Adams, Helen Lambert and the editors for comments on earlier drafts, and to Margaret Bothwell, Lynne Campbell, Elizabeth Irving, Peter Loizos and Andrew Russell for help with references.


   Footnotes
 
a The Royal College of Psychiatrists is the professional and educational body for psychiatrists in the UK and the Republic of Ireland. Among its aims are the advancement of the science and the practice of psychiatry, the promotion of research in psychiatry and the publishing of such research. As well as running its membership examination, it also visits and approves hospitals for training purposes. Back

b I have one major reservation about publishing this paper. Anthropological research in psychiatry may be used to ‘bash’ that segment of medicine, whereas the absence of such research in any other segment of medicine may be thought to imply that other doctors do these things differently, and better. The absence of such research (though see Pope4) should, rather, mean that attacks on psychiatry and comfortable assumptions about other segments of medicine are quite unwarranted. Back

c By UK law, doctors will need to have a licence from the General Medical Council to practise medicine from 2005 and doctors who wish to be so licensed must agree to take part in revalidation processes. These will partly consist of an appraisal procedure and part of this is the doctor’s participation in Continuing Professional Development (CPD). The Royal College of Psychiatrists has introduced the idea of Personal Development Plans (PDPs) for psychiatrists as the means of achieving CPD objectives. As part of their CPD requirements, each year consultant psychiatrists are expected to take part in 30 hours of ‘internal’ CPD activities, which may include local hospital-based educational activities such as Case Conferences and Journal Clubs (providing such activities are part of their own PDP and approved by the peer group that discusses each others’ PDPs). Back

d In this context, it is perhaps worth noting this second application of the phrase ‘gold standard’ and the frequent use of the word ‘flaw’, both seeming to indicate unquestionable reference to the natural, rather than man-made, value of gold and precious stones. Back


   References
Top
 Abstract
 Introduction
 The EBM meeting: account
 The EBM meeting: analysis
 Conclusion
 Acknowledgements
 References
 

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