Evidence-based Practice: What Evidence Counts?


Statistics are human beings with the tears wiped away.

Irving J. Selikoff1

In my career as a researcher, I am first and foremost a “quant”: quantitative in orientation and most comfortable with the language of numbers, rates, probabilities, denominators, and statistical assessments. As a clinician and a teacher of clinicians, I use and teach the language of evidence-based practice and population-based data as a means of guiding how I advise the women I care for, and indeed, how I sort through the advice I am given by my own health care providers. I try, however, to remain always cognizant of the dry, numerical, aggregate nature of these data. Hidden under the bell curve that summarizes the means and standard deviations of the sample being evaluated are the individual people and experiences who contributed to those averaged statistics. For all the people who comprise these data, the evidence-based statistical summaries do not and cannot describe the context and texture and richness that are the substance of their lives and their experiences of their health events. Selikoff,1 whose quotation leads off this editorial, stated this eloquently. He was the physician researcher who first linked inhalation of asbestos to pulmonary disease and cancer, and this statement is the summary sentence in an article he wrote on the risks of risk assessment. I think of this phrase as a mantra, and I quote it often as I teach principles of evidence-based practice.

Sackett and colleagues define evidence-based practice as “the integration of the best research evidence with clinical expertise and patient values.”2 As the field and the literature that define evidence-based practice have developed over the years, this, too, has become a mantra. Students of the field are reminded that, “In addition to clinical expertise, the clinician requires compassion, sensitive listening skills, and broad perspectives from the humanities and social sciences. These attributes allow understanding of patients’ illnesses in the context of their experience, personalities, and cultures.”3 It often can seem, however, that the emphasis in the evidence-based care paradigm, as it is elaborated in actual practice, is more on the evidence base and less on caring about patient values and experiences. Part of that may be because the research evidence we most often look at does not offer a voice for such experiences and values, concentrated as it is on numbers and statistics.

It may not be enough to know how important this human element is; in the world of evidence-based practice, these experiences need to be translated into evidence that we can use as we search for the best ways to deliver care. Without the context of people's lives, we risk operating from the worldview of numbers and statistics without the recognition of the tears (and smiles) that have been wiped away by the process of aggregating and summarizing all their data. In the 30 years I have served in some capacity on the Editorial Board of this Journal, I have observed a quantum shift toward more submissions and published papers that do exactly this: provide a qualitative context for practice that helps us see past the numbers to the reality of people's lives.

In this issue, Gurnah et al4 help us to understand the problematic experiences of 1 group of refugee women in accessing reproductive health care, where cultural dissonance and differing worldviews can create inaccessibility beyond that of finances and geography. There is no simple statistic that could possibly convey the feeling that one hears in this woman's voice: “Sometimes I may understand what the doctor is saying, and the person with me may understand, but they don't accept the person or me.”4 I am shaken by her experience of her health care, in an era in which we at least seem to acknowledge how important culturally appropriate care is. We need to hear these voices before we can acknowledge and address issues that disrupt care—such as dominant worldviews, power imbalances, and paternalistic clinical partnerships—and provide care with cultural humility.5 Without listening, we risk dismissing this woman as illiterate or uncooperative with the advice we give. Without hearing her, we risk not being caregivers but merely evidence providers.

In a similar vein, Halperin6 addresses how clinicians who experience adverse outcomes in the births they attend can be marked for the rest of their lives. The exemplars from the midwives in this study easily could have remained hidden behind some summary statistics on the risk of adverse events in midwifery care or the association between such outcomes and burnout in the health professions. But in this qualitative study, the words of the midwives involved lend emotion and immediacy to the problem; indeed, they let us see the tears before they are wiped away. In much the same way, it is the words of the midwives in Davis’ qualitative study of midwives and normalcy in childbirth7 that let us experience the lived tenacity of commitment that is a hallmark of our profession. We all have felt these emotions and often discuss them with other midwives, perhaps at local and national meetings when the talk turns to what it is like to do what we do. But qualitative studies such as these take those words and give them a larger voice that stretches beyond the confines of midwives’ practices and meeting halls and, with the rigorous methodology of qualitative research, elevate them from individual anecdote to scholarly evidence.

We know, as midwives, that caring comes from relationships with women. Listening to women is our own mantra, a hallmark of the relationships we have within our profession and with the women we care for. But the words we hear also need to be part of the evidence base that drives what we do. Dissemination beyond 1-to-1 relationships may be as important as listening in the first place. I read these studies as carefully as I do those that report statistics, and I am grateful to our growing ranks of qualitative researchers for giving voice to the human beings with tears on their faces.