EVIDENCE BASED MEDICINE

EVIDENCE BASED MEDICINE:

A HISTORICAL AND REALISTIC APPRAISEMENT

SO THAT WE KNOW WHAT ACTUALLY WE ARE TALKING ABOUT

Evidence Based Medicine has been bandied about for some time, usually whenever a specialist wants to put a generalist in his/her place. Recently, I was at the receiving end of it when I stood up at a meeting to speak on behalf of a treatment modality that I feel would benefit the common person no end if only the generalists would learn to use it. Even though I felt that I was correct, the result was that I was passed over as not being scientific enough. As a result, I have read up and here I have given a synopsis of my conclusions. One of the firsr revelations is that EBM does not mean that only irrevocable scientific research can justify a treatment modality. This misconception is in most minds whenever the term Evidence Based Medicine is used. As a result one is made to feel guilty when one cannot immediately quote the scientific evidence for our choice of treatment. The truth is that EBM is actually the subjective result of a combination of different types of both objective and subjective evidences, ranging from random controlled trials to clinical cases and anecdotes. While recognizing that this synopsis is not a final statement on it, nevertheless it is a helpful note on what EBM actually means and how we should use it practically.

All medicine and dentistry are based on evidence to a greater or lesser extent. The perennial question to be asked should always be what type of evidence and how good is it? The following is a basic timeline of the modern development of the term Evidence Based Medicine.

1. Professor Archie Cochrane, a Scottish Epidemiologist in his retirement years wrote a book entitled, “Effectiveness and Efficiency: Random Reflections on Health Services” in 1972.

2. It had a landmark effect on the health profession because the question of how really effective are our curative procedures was an issue that had not been addressed aggressively for some time. Historically, it is a question that has always been in the mind of the deliverers of treatment to help them to decide on a hopefully successful course of treatment. I am of course referring to serious, ethically inclined practitioners and not charlatans who are just out for a fast buck. Ancient medical texts usually have at its basis some amount of logic, passed down assumptions and usually common sense with an occasional dash of magic and illogicality.

Modern western based medicine has progressed ever since they came out of the dark ages (with a heavy push from the indomitable Martin Luther of the Renaissance and Reformation fame). Logic and rationale were applied seriously to cures and treatment of diseases, and thus western based medicine proceeded to dominate the world scene because many of their treatments work somewhat and sometimes spectacularly, and is based on some rational commonsense. However, along the years, thinking had stagnated somewhat so that by the time Professor Cochrane offered up his book, it met a crying, but unspoken felt need.

3. Professor Cochrane’s work currently is honored and propagated in centres of evidence-based medical research called “Cochrane Centers”.

4. The term “Evidence Based Medicine” or EBM for short was first coined and used in a published medical article by Guyatt et al in 1992.

5. Professor David Sackett in the 1996 editorial of the British Medical Journal defined EBM as, “EBM is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” Let me paraphrase, “Evidence based medicine is the wise use of current research in curing individual patients.” The original philosophy of EBM does not mean pitting research evidence against clinical experience and individual patient values. Instead, it is the integrating of these three, namely research evidence, clinical experience and individual patient values in order to come out with a suitable and balanced course of treatment.

6. Strength of evidence can be generally divided as follows:

            Level 1 :  Random Controlled Trial

            Level 2 :  Controlled Trial

            Level 3 :  Clinical Experience

            Level 4 :  Hearsay

7. One more consideration to take into account in deciding on a treatment modality for a patient should be the question, “ What is the purpose and intention of using the principle of EBM in the treatment of patients?”

            Is it for the patient’s sake to cure?

Or        Is it for the doctor’s sake to justify their conscience or for monetary gain?

Or        Is it for the administration’s sake to streamline operations?

The answer, I believe often lies and should lie somewhere between these considerations.

By:

Dr Chow Kai Foo

BDS Singapore

FDSRCS England

Academy of Medicine Malaysia

July 2012

Cognitive schema and naturalistic decision making in evidence-based practices. Department of Psychiatry, Yale School of Medicine, CMHC, 34 Park Street, Room 144, New Haven, CT 06508, USA. paul.falzer@yale.edu

J Biomed Inform. 2004 Apr;37(2):86-98

The Internet Journal of Allied Health Sciences and Practice

Evidence Based Practice: Misconceived perceptions and warped realities

Dr Saravanan Kumar  Volume 8 Num 4

Evidence Based Medicine Wikepedia

Evidence Based Practice and the Principles of Effective Practice by The Open University