Defining a Proper Background for Discussing Evidence-based Medicine

Abstract

The Evidence-based Medicine (EBM) movement has provoked strong restatements from within the clinical world about the essence of the patient-clinician relationship and the balance between scientific approach and personal experience. Some commentators saw the movement partly as an attempt by clinicians to keep control of decision-making, in the face of governments set on increasing intervention in the previously relatively autonomous professions. Health policies worldwide, however, reveal the growth of mechanisms aimed at establishing parameters for acceptable clinical practice and a range of apparatus for monitoring and enforcing these parameters. On another track, some critics have questioned the movements sometimes exclusive focus on one particular research design (i.e. the randomised controlled trial) as unnecessarily narrow, and reinforcing the cultural and political values of particular research groups. Also embedded in this phenomenon is a staging of the confrontation between science and progress on the one hand and myth and reaction on the other. It is the aim of this paper to discuss the extent to which the current debate addresses the real issues, or is rather confounded by extraneous factors. We will do so by starting from the personal conviction that there is within the current debate a mixture of epistemological confusion about the proper definition of "proof" and "evidence resistances to cultural and professional changes from within the medical profession, misplaced criticisms from EBM-skeptics and, to some extent, over-enthusiasm and reductionism from those who fail to recognise EBMs practical and methodological limitations. In this paper we will therefore briefly discuss: a) what is EBM and what it is not; b) the difficulties related to the understanding of uncertainty and the appropriate role of pathophysiological reasoning vs. the use of empirical evidence; c) EBMs main limitations and enemies; d) the proper directions that clinical practice and health care policies should pursue to take advantage of the innovations that EBM can bring about. In the Appendix, some examples drawn from the Cochrane Library wifi be used to illustrate where systematic reviews of available evidence can and cannot be used in order to inform clinical practice in a meaningful way. © 2005 Springer-Verlag Berlin Heidelberg.