Is evidence-based medicine broken?

Posted on 4th March 2014 by Alice Buchan

Last month, this article was published by The BMJ, boldly entitled “Evidence-based medicine is broken.” In this, Des Spence argues that evidence-based medicine (EBM) has become a problem in itself rather than a solution [1]. He suggests that the doctrine of following the evidence leaves no flexibility in clinical decision-making, no room for context or the professional judgment of the clinician. He also claims that EBM is one of the reasons behind the growing burden of overdiagnosis and overtreatment.

I would argue that using Sackett’s 2000 definition: “the integration of the best research evidence with clinical expertise and patient values” [2], EBM as a concept remains sound. Putting it into practice appears to cause the issues Spence describes.

In terms of inflexibility, again I would argue that misconceptions of EBM and how it is practiced fuel this. In Sackett et al.‘s 1996 paper [3], they describe how EBM does not obviate the need and space for judgement.

“Evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice, it cannot result in slavish, cookbook approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision. …Clinicians who fear top down cookbooks will find the advocates of evidence based medicine joining them at the barricades. [2]”

He also raises the issue of the quality of the pool of evidence upon which guidelines and decisions are based. The issues that he identifies as threats to the quality of EBM, such as a lack of publication of some trials, conflicts of interest in the funding of research and development of guidelines. Whilst undoubtedly his criticisms are sound, it is not all doom and gloom. Parts of the practice of evidence-based medicine: using appraising critically and using the evidence judiciously, should mean that the appropriately sized pinch of salt is added when applying the evidence in conjunction with individual expertise and the needs of the individual patient to reach a clinical decision.

I regard EBM as a work in progress, with each iteration better than the previous. The problem isn’t EBM itself, but that is not and will never be perfect. As long as we recognise this and use the evidence judiciously to guide both clinical decisions and future research, it will continue to improve. Imperfect it may be, but broken it is not.

Links

[1] Spence, D. Evidence based medicine is broken? BMJ 2014;348:g22

[2] Sackett, D. L. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). Edinburgh; New York: Churchill Livingstone.

[3] Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71-2

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