Evidence Based Medicine
Currently, there is the belief that Evidenced Based Medicine (EBM) is limited only to the evidence obtained via the 5 senses and Random Controlled Trials (RCT). In so doing we have taken on board the disinformation and propaganda perpetuated by the ‘Cult of the RCT’.
It should also be noted that those who limit sources of evidence to only RCT’s are focusing primarily on the internal validity of such studies. In so doing they disregard the equally important evidence of external validity based on data obtained through clinical effectiveness.
However, when one begins to delve into the origins of Evidence Based Medicine it quickly becomes evident that the founder of EBM, in fact, articulated a holistic approach that included not merely systematic trials but also the response of individual patients to a clinical procedure.
The most common definition of EBM is taken from Dr. David Sackett. EBM is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett D, 1996)
EBM is the integration of clinical expertise, patient values, and the best evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education, and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology. (Sackett D, 2002)
The evidence, by itself, does not make a decision for you, but it can help support the patient care process. The full integration of these three components into clinical decisions enhances the opportunity for optimal clinical outcomes and quality of life. The practice of EBM is usually triggered by patient encounters which generate questions about the effects of therapy, the utility of diagnostic tests, the prognosis of diseases, or the etiology of disorders.
Evidence-based medicine requires new skills of the clinician, including efficient literature searching, and the application of formal rules of evidence in evaluating the clinical literature.
The Six Steps in the EBM Process
Start with the patient – a clinical problem or question arises out of the care of the patient
Construct a well-built clinical question derived from the case
Select the appropriate resource(s) and conduct a search
Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice)
Return to the patient – integrate that evidence with clinical expertise, patient preferences and apply it to practice.
Evaluate your performance with this patient
These individualized patient-oriented steps are a far cry from applying the dehumanized statistical results of RCT drug trials upon arbitrarily selected disease labels. Rather EBM does not dictate the specific trial and experience-based methods for obtaining the evidence.
In fact, the patient and her/his response included along with the practitioner’s observation of the patient as well as the practitioner’s experience all become an integral collective in the treatment of the patient. Any valid systematically collected data that is relevant is also to be considered in the patient treatment picture that is being developed.
This approach blows wide open the simplistic fundamentalist dogma currently being spewed forth by the ‘Cult of the RCT.’ Rather, what David Sackett has formulated is a holistic process with which homeopathy has now been conversant and applying for the past 200 years.
It is about time that we begin to acknowledge the holistic basis of Evidence Based Medicine and stop taking on board the snatched up stick of a limited definition and allow ourselves to be beaten by it.
Hart, Julian What evidence do we need for evidenced based medicine? Journal of Epidemiology and Community Health 1997;51:623-629. NCBI.NLM.NIH.gov
Sacket, David, et al Evidence based medicine: what it is and what it isn’t. BMJ 1996,312:71