Thursday, December 30, 2004

Evidence Based Medicine- The Dark Side Part One

The most recent definition of Evidence based medicine (EBM) preempts criticism in its inclusiveness. " The integration of the best evidence with clinical expertise and patient values" Previous criticism of EBM claimed there was neglect of clinical expertise and the patient's values and desires.
Who could object to the inclusive definition." It is mom and apple pie and more pie. Surely there could be no dark side to that.
However, when most physicians think of EBM,their thoughts focus on randomized control trials (RCT) and meta-analysis rather than the all embracing arguably vacuous definition. This is because RCTs and meta-analysis are really what EBM is all about.
A darker side could emerge if in the zeal to champion the RCTs the other factors one needs to consider are neglected. Those factors are, of course, prior evidence and biological plausibility.Dr. Steven Goodman from Johns Hopkins has cogently argued for this as have Sehon and Stanley in a wide ranging and very interesting philosophical analysis of the EMB issue.
Another author, Miles Little,(ANZ Journal of Surgery.Vol.73,issue 4, pg 177, April 2003) speaks of EBM's "cult status" and lists 8 areas of concern including its unwitting paternalism,its unstable truths and its reductionism.
Bandolier ( a journal of evidence based medicine) admits that references to EMB can serve as a talisman. To say that the author's position is evidence based is supposed to end the discussion much as saying "its God's Will" might have served in an earlier era.
In anyone thinks there will always be an arrow from RCT to clinical algorithm for all or most clinical problems here are few of reasons why that will not be true. There is not enough time or money or interested funding groups to do all the RCTs needed for all the issues. RCTs may be contradictory (i.e. ALLHAT and the 2Nd Austalian National blood pressure study). RCTs become outdated as technical advances pile up faster that RCT can catch up.
If there are problems and limitations with RCTs, there are meta problems and issues with meta-analysis, an issue to consider later.

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