The question posed in the title of this essay that we are considering, requires deliberation of not just Evidence-based medicine (EBM), but general clinical practice, as well as what history has taught us– with reference to particular cases. There have been many situations where the lack of EBM has been detrimental to the health of many patients – this was mostly due to gaps or incompletion in knowledge. In other circumstances, mainly with regards to earlier cases, EBM was just not accepted. The general consensus was a query of why clinicians should change their methods of practice from largely accepted wisdom I exchange for new theories. Even though, in many cases, these upcoming theories had no direct rebuttals, such as when Marshall and Warren, found that stomach ulcers were caused by the bacterium Helicobacter pylori and not just by the accepted causal mechanism at the time which was increased acidity caused by stress (Marshall, 2008). Furthermore, at times, pathophysiological reasoning about a disease and patient could lead to the adoption of interventions that seem somewhat obvious with little testing– but these could prove rather therapeutically unbeneficial. An important example, was that of the drugs prescribed to suppress arrhythmias in patients who suffered from myocardial infarctions – as they were seen to suddenly die within months of the attack. It was later found by the work of two double-blinded, randomised controlled trials (RCTs) that these drugs in fact increased the number of deaths in patients (Bird). There are many examples of the same ilk.
Firstly, we must acknowledge what exactly EBM is, there a multiple different acronyms and names for EBM, such as evidenced based practice. Nonetheless, the underlying principal is that EBM when clinical decisions are made, they are done so on the basis of the most recent, reliable and documented scientific evidence. In 1996, the definition of EBM made by Sackett et al, explicitly highlighted that “evidence-based medicine is the conscientious explicit and judicious use of current best evidence in making decisions about the care of individual patients”. This definition sounds quite ideal, but it does not prove so in practice. The concept itself seems to contradict itself. The trials and studies advised by EBM for use, do show summary data, therefore are we considering anomalies or extreme variances that are not being accounted for. Could the particular patient which the clinician is treating at the time, fall in the anomalous category? As such, are we considering the care of the individual patient? The argument made my many in the healthcare profession is that clinical practice is more complex than trials. They debate that research is focused on treatment and medical interventions. The recommendations for prognosis and diagnosis are abandoned (Hemingway et al, 2009). The patient and doctor themselves are possibly more equipped to tailor the treatment to cater to the individual needs of that particular patient.
RCTs have been one of the focal points of transgression for EBM rejecters. The argument some make is that, EBM glorify RCTs and dogmatically discard other sources of valid data (Borgerson, 2009). A question of lexicography is raised, suggesting that RCTs are always and will always be the better type of study, and this has already been disproved throughout history. The Cochrane Collaboration is an organisation formed in 1993 to organise medical research findings so that healthcare professionals are aided whilst making EBM-based decisions. The collaboration has recently recommended a new method to grade evidence from high quality (usually RCTs) to very low quality (usually observational studies). Each can be lowered demoted or promoted based on factors such as deficiencies in validity and precision, inconsistencies, publication bias or strong association, dose-response effects respectively (Conacto et al, 2000). Bird states in our lecture notes that the justification for this EBM hierarchy is to reduce error and the studies lower down the hierarchy are more disposed to error through study design etc. The effectiveness of RCTs are often unassessed due to practical and ethical obstacles, as such almost forcing EBM to consider other studies. In current clinical practice, many medical interventions have been accepted without any RCT evidence at all. The most famous and successful of these interventions include suturing of large wounds, use of defibrillators during ventricular fibrillation and of course, the use of insulin to treat diabetic patients (Glasziou et al, 2007). This makes one question when and to what extent RCTs are necessary, and whether the importance focused on RCTs are just. And thus, how correct EBM is for the use of clinicians etc. Bird, during our lectures, also suggested that systematic reviews which includes the results from more than one study will reduce the chance of error through poor implementation, statistical errors etc. The combination of studies will allow for increased possibility of eliminating errors.
Indeed, EBM carries many important advantages but the extent of how successful these are in conjunction with clinical practice is debatable. In my opinion, the underlying principles of EBM are not inherently unsound. EBM perhaps still has some way to go in terms of the hierarchy of EBM data, and integration in manner accepted by clinicians. Especially without raising the debate of experience vs EBM. I think it is unfair to state that EBM cannot “be correct” but it is better to state that it is correct to an extent or not always correct. EBM consists of vital information of the rapidly evolving medical world, and it is always important for any healthcare professional to be on top of this to allow them to make well-informed decisions. However, guidelines produced from EBM should not be strict or enforced, and should just simply be guidelines that guide clinicians when they are initially unsure of what clinical decision to make. If current criticisms of EBM are acted upon, perhaps the use of EBM will be more of a correct account that doctors can use to make clinical decisions.