Thursday, June 10, 2010

Evidence Based Medicine: Why I Became Weary of Those Who use This Term?

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In short, in an effort to make Evidence Based Medicine (EBM) an arching philosophy of practice, EBM had to include evidence that is considered poor by EBM’s very own criteria. The scope of EBM must be narrowed to only be a research paper analysis tool. Unless we do this, we will continue to undermine the quality work produced by the McMaster group and many others.
After limiting the scope of EBM, we should come up with new and practical tools that allow us to be conscientious, explicit and judicious when making decisions about the care of individual patients. Along this journey, we will probably employ new fancy names to describe this philosophy of practice. These names will not include EBM.

Evidence Based Medicine (EBM) has transformed medicine in a good way. Yet unfortunately, EBM is becoming a buzz word and is often use inappropriately. I am in the process of writing my view of how the evidence in medicine should evolve; in detail. But, this is taking more effort than I anticipated. So, for the time being, I thought of writing this short post summarizing some of my thoughts on the matter.

To start, I think the main fault for the inappropriate use of EBM principles falls on those who actually proposed EBM. McMaster researchers that coined the term EBM, described EBM as a method to systematically analyze published research, and to combine this analysis with patient evidence to make clinical decisions (Oxman et al. 1993). Patient evidence includes patient's clinical history, examination, and investigations.

They, then, published a series of articles that outline how to analyse published research. (Oxman et al. 1993)
To fend off criticism, Sackett et al. (1996) published an editorial titled: Evidence Based Medicine: What it is and what it Isn't, that clarified their stance. They defined EBM as:

the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

In this editorial, authors stated that EBM is practiced by integrating individual clinical expertise with the best available external evidence.

One of the main criticism of EBM ,as initially proposed in 1992 and 1993, was its undermining of clinical expertise. To clarify (or may be slightly modify) their stance - they now ask to combine the analysis of research papers with “clinical expertise” which is more encompassing than “patient evidence".

Therefore, a flood of so called evidence based guidelines started to appear. These guidelines would propose recommendations that are based on best evidence as per EBM criteria. But, as this is often lacking, the “clinical expertise” of experts is often used. So, the clinical expertise of these experts would be combined with clinician’s own clinical expertise to reach clinical decisions. However, external clinical expertise is considered poor evidence as per the criteria laid out by EBM proponents. (which just does not sound right! especially, for younger physicians like me who's expertise is developing by using these same guidelines.

I believe that Sackett et al. should have backed off by limiting EBM to being a tool to analyse research papers. As I will detail in my upcoming post, EBM does not offer the appropriate tools to apply evidence to individual patients’ cases.That is, EBM does not offer the tools to combine individual patients’ evidence with external evidence. EBM proponents just assume that clinicians would combine these two sources of evidence in a proper manner. But, this doesn’t always happen. Many are using their poor understanding of what EBM as an excuse for bad clinical decisions.

You may or may not agree with me. But, I had to write this post; as sadly, I am becoming more weary of those that use the term EBM than those who don't.  Arguably, those who don't shout about EBM to support their opinion must think more deeply and be more explicit in supporting their decisions.

Oxman, A.D., Sackett, D.L. & Guyatt, G.H., 1993. Users' guides to the medical literature. I. How to get started. The Evidence-Based Medicine Working Group. JAMA: The Journal of the American Medical Association, 270(17), 2093-2095.

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS., 1996. Evidence based medicine: what it is and what it isn't. BMJ (Clinical Research Ed.), 312(7023), 71-72.
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