Comments on: The limits of evidence-based medicine http://www.dbskeptic.com/2008/08/17/the-limits-of-evidence-based-medicine/ Skepticism. Critical thinking. Podcast. Community. Tue, 06 Jan 2009 10:46:25 +0000 http://wordpress.org/?v=2.6.5 By: David Annis http://www.dbskeptic.com/2008/08/17/the-limits-of-evidence-based-medicine/#comment-573 David Annis Thu, 18 Sep 2008 17:08:55 +0000 http://www.dbskeptic.com/?p=105#comment-573 I am not trying to say that there is no value in EBM, that there are not attempts to be as consistent as possible, or that in best practice the clinician's judgment is not valued. However, there are legitimate concerns surrounding all of these areas that affect EBM's implementation in the real world. I have read about and spoken to physicians that feel they have been constrained based on EBM. These concerns are not unique to me. See, for example: http://medir.ohsu.edu/~hersh/ebcm-04-ebm.pdf http://content.onlinejacc.org/cgi/content/full/4/5/954?ijkey=f102d3012381e501834c80f23bbcb89de29ae33c&keytype2=tf_ipsecsha A letter to the editor of Anesthia Analgesia ( http://www.anesthesia-analgesia.org/cgi/content/full/95/6/1817 ) begins "Proponents of evidence-based medicine (EBM) insist that reviewers search thoroughly for all evidence relevant to a clinical question. Yet when reviewing the subject of EBM itself, these same proponents seem curiously blind to criticism." I hope to subject EBM to the same skeptical review that this wonderful site gives to a variety of other topics. The letter provides a lot of additional references. I do not and will not argue that EBM is worthless, just that it has limitations and biases that we must be aware of if we are really skeptics. In my own opinion, some of the issues with EBM are exacerbated when powerful parties (private insurers) can use it as an additional reason to limit the application of clinical judgment by physicians. I am not trying to say that there is no value in EBM, that there are not attempts to be as consistent as possible, or that in best practice the clinician’s judgment is not valued. However, there are legitimate concerns surrounding all of these areas that affect EBM’s implementation in the real world. I have read about and spoken to physicians that feel they have been constrained based on EBM.

These concerns are not unique to me. See, for example:
http://medir.ohsu.edu/~hersh/ebcm-04-ebm.pdf
http://content.onlinejacc.org/cgi/content/full/4/5/954?ijkey=f102d3012381e501834c80f23bbcb89de29ae33c&keytype2=tf_ipsecsha

A letter to the editor of Anesthia Analgesia ( http://www.anesthesia-analgesia.org/cgi/content/full/95/6/1817 ) begins “Proponents of evidence-based medicine (EBM) insist that reviewers search thoroughly for all evidence relevant to a clinical question. Yet when reviewing the subject of EBM itself, these same proponents seem curiously blind to criticism.” I hope to subject EBM to the same skeptical review that this wonderful site gives to a variety of other topics. The letter provides a lot of additional references.

I do not and will not argue that EBM is worthless, just that it has limitations and biases that we must be aware of if we are really skeptics. In my own opinion, some of the issues with EBM are exacerbated when powerful parties (private insurers) can use it as an additional reason to limit the application of clinical judgment by physicians.

]]> By: Steven Novella http://www.dbskeptic.com/2008/08/17/the-limits-of-evidence-based-medicine/#comment-564 Steven Novella Sun, 14 Sep 2008 11:06:29 +0000 http://www.dbskeptic.com/?p=105#comment-564 David, I think you need to read a bit more about Evidence-Based-Medicine (EBM). All of the concerns you raise are taken into consideration when evaluating the evidence for an intervention. Reviews are generally done by academics, many specifically done for Cochrane or other EBM databases - insurance companies and pharmaceutical companies have no input. The biases of the reviewers is also a factor, of course. And the literature is a moving target. So seeing multiple reviews is helpful. Also - groups like Cochrane have very strict published methods for how to do a systematic review and score a treatment. This does not remove judgment from the equation, but does try to be as consistent as possible. Further - EBM is NOT about reducing the practice of medicine to a flow chart. This is really just a misconception. EBM is about reviewing evidence and putting it into the hands of clinicians at the point of patient care. It recognizes explicitly the role of the experience and judgment of a clinician and the individualization of care. Really, you completely mischaracterized EBM in your last paragraph. From the Cochrane website: http://www.cochrane.org/docs/ebm.htm Evidence-based health care is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factors [1]. Evidence-based clinical practice is an approach to decision-making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best [2]. Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research [3]. David,

I think you need to read a bit more about Evidence-Based-Medicine (EBM). All of the concerns you raise are taken into consideration when evaluating the evidence for an intervention. Reviews are generally done by academics, many specifically done for Cochrane or other EBM databases - insurance companies and pharmaceutical companies have no input. The biases of the reviewers is also a factor, of course. And the literature is a moving target. So seeing multiple reviews is helpful. Also - groups like Cochrane have very strict published methods for how to do a systematic review and score a treatment. This does not remove judgment from the equation, but does try to be as consistent as possible.

Further - EBM is NOT about reducing the practice of medicine to a flow chart. This is really just a misconception. EBM is about reviewing evidence and putting it into the hands of clinicians at the point of patient care. It recognizes explicitly the role of the experience and judgment of a clinician and the individualization of care. Really, you completely mischaracterized EBM in your last paragraph.

From the Cochrane website: http://www.cochrane.org/docs/ebm.htm

Evidence-based health care is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factors [1]. Evidence-based clinical practice is an approach to decision-making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits that patient best [2]. Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research [3].

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