Evidence-based medicine

Evidence-based medicine is defined as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." [1]. Better known as EBM, evidence based medicine began being discussed in 19XX, and now has . Why should such an approach to clinical medicine merit its own name, let alone another acronym in the medical literature? Don't physicians ordinarily conscientiously and judiciously use scientific evidence in treating patients? Isn't that simply routine medical care?

In fact, most of the specific practices of physicians and surgeons are based on traditional techniques learned from their seniors in the care of patients during training, that are modified with personal clinical experience and information gleaned from the medical literature and continuing education courses. Although these practices almost always have a rational basis in biology, the actual efficacy of treatments is rarely explicitly proven by experimental trials in people. Further, there is a lag time between evaluating procedures, treatments and tests in medical care and establishing them as routine.

Evidence-based medicine seeks to use practices that has been shown, through the scientific method to have validity by empiric proof. As such, it currently encompasses only a very small minority of actual clinical practices. More often, recommendations are made on the basis of best evidence that are reasonable, but not proven. Evidence-based medicine is also a philosophy, however, that seeks to validate practices by finding proof.

This article will discuss the field of evidence based medicine. In order to understand this approach to clinical care, some background in the history of medicine, experimental evidence in clinical medicine, and the ethics of medical experimentation must also be included.This philosophy is not restricted to medicine among the health sciences, there are many nursing and other allied health science articles in the published peer-reviewed literature of these professions that use the term. Evidence-Based Health Care extends the application of the principles of EBM to all professions associated with health care, including purchasing and management [2].

Experimental trials in clinical medicine:producing the evidence

Randomized controlled clinical trials

"A clinical trial is defined as a prospective scientific experiment that involves human subjects in whom treatment is initiated for the evaluation of a therapeutic intervention. In a randomized controlled clinical trial, each patient is assigned to receive a specific treatment intervention by a chance mechanism."(Stanley K. Design of randomized controlled trials. Circulation. 115(9):1164-9, 2007 Mar 6. UI: 17339574)

Incorporating evidence into clinical care

Practicing clinicians usually cite the lack of time for reading newer textbooks or journals. However, the emergence of new types of evidence can change the way doctors treat patients. Unfortuantely the recent scientific evidence gathered through well controlled clinical trials usually do not reach the busy clinicians in real time. Another potential problem lies in the fact that there may be numerous trials on similar interventions and outcomes but they are not systematically reviewed or meta-analyzed.

Medical informatics

An essential adjunct to the practice of evidence-based medicine (EBM) is medical informatics (MI) which focuses on creating tools to access and apply the best evidence for making decisions about patient care [Sackett et al, 2000].

Before practicing EBM, informaticians (or informationists) must be familiar with medical journals, literature databases, medical textbooks, practice guidelines, and the growing number of other dedicated evidence-based resources, like the Cochrane Database of Systematic Reviews and Clinical Evidence [Mendelson and Carino 2005].

Similarly, for practicing medical informatics properly, it is essential to have an understanding of EBM, including the ability to phrase an answerable question, locate and retrieve the best evidence, and critically appraise and apply it [Hersh 2002, Shearer et al., 2001].

References

1. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. 2nd ed. New York, NY: Churchhill Livingstone, 2000.
2. Mendelson D, Carino TV, Evidence-Based Medicine In The United States-De Rigueur Or Dream Deferred? Health Affairs, 2005, 24: 133 - 136. doi: 10.1377/hlthaff.24.1.133
3. Hersh W, Medical informatics education: an alternative pathway for training informationists, J Med Libr Assoc, 2002, 90(1): 76 - 79.
4. Shearer BS, Seymour A, Capitani C. Bringing the best of medical librarianship to the patient team, J Med Libr Assoc 2001; 90: 22-31.

See also

• Clinical decision support system
• Marsha Angell

External links

• ACC.org - 'What Is Evidence-Based Medicine?' American College of Cardiology
• AHRQ.gov - 'U.S. Preventive Services Task Force (USPSTF)', Agency for Health Care Research and Quality
• BEEMCourse.com - 'The Best Evidence In Emergency Medicine (BEEM) Team' Group based out of McMaster University (Hamilton, Ontario, Canada) that actively reviews the best emerging evidence based research in emergency medicine.
• BMJ.com - 'Evidence based medicine: what it is and what it isn't: It's about integrating individual clinical expertise and the best external evidence', (editorial) British Medical Journal, vol 312, p 71-72 (January 13, 1996)
• BMJ.com - 'Evidence based medicine: Socratic dissent', (Education and debate) British Medical Journal, vol 310, p 1126-1127 (April 29, 1995)
• CEBM.net - Oxford Centre for Evidence-Based Medicine (UK)
• CMAJ.ca - 'Evidence-based medicine: a commentary on common criticisms', Dr. Sharon E. Straus, Dr. Finlay A. McAlister, Canadian Medical Association Journal, Vol 163, No 7, pp 837 - 841 (October 3, 2000)
• Cochrane.org - 'The Cochrane Collaboration: The reliable source for evidence in healthcare' (systematic reviews of the effects of health care interventions), Cochrane Library
• EBOnCall.org - 'Evidence compendia' (evidence-based summaries of 38 on-call medical conditions), Evidence-Based On-Call (EBOC)
• Evidence-based medicine, What is ? - The What is...? series explains the key concepts in a clear, concise and accessible format.
• GPNoteBook.co.uk - 'Evidence-based medicine (EBM)', General Practice Notebook
• HERTS.ac.uk - Evidence-Based Medicine', University of Hertfordshire
• JournalReview.org - 'An unbiased forum for review of the medical literature', An On-Line journal club
• JR2.ox.ac.uk - 'Bandolier: Evidence-based thinking about health care', Bandolier (journal)
• medlib.bu.edu = 'Introduction to Evidence-Based Medicine' Boston University Medical Center Library
• MJA.com.au - 'Evidence-based medicine: useful tools for decision making', Jonathan C. Craig, Les M. Irwig, Martin R. Stockler, Medical Journal of Australia, vol 174, p 248-253 (2001)
• SHEF.ac.uk - 'Netting the Evidence: A ScHARR Introduction to Evidence Based Practice on the Internet' (resource directory), University of Sheffield
• TRIP Database - 'TRIP Database - EBM search engine' (resource directory), TRIP Knowledge Service
• BMJ.BMJjournals.com - 'Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials', Gordon C S Smith, Jill P Pell, British Medical Journal, Vol 327, pp 1459-1461 (20 December, 2003) (An entertaining study showing that situations still exist where RCTs are unnecessary.)