I just got back from a great meeting with my friends at the Canadian Best Practices Initiative (CBPI) at the Public Health Agency of Canada (PHAC). PHAC is in the process of transforming its Centre for Chronic Disease Prevention and Control (CCDPC) and this meeting was an opportunity to see how the CBPI fit within the new structure. Look for good things to come out of this centre in the near future.
Like clockwork, the issue was raised of whether the Canadian Best Practices Portal (CBPP) should open itself up to other, less rigorously evaluated practice examples and I strenuously encouraged their inclusion. I have been a strong supporter of the development of the CBPP for about the last 5 years but the concept of “Best Practices” in public health has always seemed a bit slippery.
The idea of using the best available evidence is unimpeachable, of course, but, tested against questions like “for who”, “where” and “when”, Best Practices are often exposed to be fairly limited opportunities. Best Practices probably do exist but they are probably not the broad spectrum panacea that they are often portrayed.
The internet allows ready access to a host of Best Practice repositories and this plenitude exposes another challenge with the concept: “Best” very much depends on the person or organization in the judge’s seat. Were a given piece of practice truly the “Best”, one would expect it to propagate like a virus across multiple sites. This is rarely the case. This isn’t terribly surprising, though. Different sites have different funders and each funder has its own focus and drivers. It is interesting to consider that Best Practices might be kept from going viral precisely because the various repositories are unintentionally quarantined from one another. It seems to me that we need to start practicing a little unsafe Knowledge Exchange to get things going!
As with all contagious entities/ ideas, however, one needs to be careful. We want some ideas to thrive and we want to drop the bomb on others. The evidenced based practice movement grew in response to the tainted wells of ad hoc and/or outdated practice. While we all would agree that we want to propagate the best possible ideas, what if ad hoc and instinctive evidence is all that is available to support a particular piece of practice in a particular context? What then? By definition, we would be in possession of the best available evidence, but would we feel confident that we could inoculate our children with it?
Maybe yes and maybe no. You clearly wouldn’t want to stake your $1M public health budget on an untested idea but it probably wouldn’t hurt to run a couple of little pilot projects to test the water. It is only through performing these natural experiments that we can truly generate the volume of evidence needed to figure out what works, for who and in which context. But who is going to perform these experiments? Who will collect and analyze the data? The CAPTURE Project thinks that, by building a web based evaluation platform, on the ground practitioners will be able to gain insights about what works –and, more importantly, probably won’t work– for them in their context. CAPTURE hopes to help engender a culture of testing and recording the adaptation of practice on the ground so that practitioners can learn from their own work and they can share these findings with the broader public health community. For my money, this is just the kind of “unsafe” knowledge exchange that would help the field move to a more modern, collaborative and practitioner-focused form of knowledge engagement.
March 18, 2011 at 8:00 am
David,
I think you have a brilliant idea here….though be ready for silent (strong & insidious) opposition. There are entrenched interests in the “health care” industry that want to retain a stranglehold on all treatment programs/drugs/etc.. I think those groups will endeavor to promote fringe (aka sketchy people) only so they can knock them all down later as “quacks.” After spending my life, with raising 4 kids, in the American health system….and seeing that both mature and devolve simultaneously (mature on advancement of science, devolve in preventative medicine and common sense ….leaving all to the drug companies, and their sponsored (aka highly directed) research. And, THEN spending lots of time in Canada and France; it is clear that an unassailable knowledge base (accumulated from live clinical experience) is the only way to regain some semblance of humanity in health maintenance, prevention, and sane treatment programs. The horrendous thing? For the amount of money and effort thrown at healthcare, we get very little return (i.e. in improved health). Life expectancy stats are one of the things that are touted; but who wants to live an extended life tied to machinery and drug therapies?? Yes, they are good to have when you need them…..but the more relevant question is: why do we need them so much lately? ;-)
The “corporatization” of life has led to a profit driven existence….where the food supply is at serious risk (i.e. e. coli contagion as ‘side effect’ of homogenized and medicated animal farm factories), Fast “Food” is more for profit than nutrition (i.e. leading cause of obesity & further complications), and the first response to almost any medical situation has become ‘medicate first’ (aka drug company propaganda, and ‘demand pull’ prescribing). These things started in the U.S., but have crept into Canada; and now threaten Europe. But still, Canada and Europe are the best possible areas to reverse the tide…..and that will come from observing, and quantifying, clinical evidence. Human studies are scary, and the corporate interests play on that fear by playing in the margins created by Very narrow research that focuses on minute details (usually to support one fragment the company is trying to get past govt regulators.) We can’t change a corrupted research system, but we can question it through objective and solid clinical evidence of what is happening to real people and the efficacy of treatment regimes.
More power to you and your CAPTURE Project efforts :-)