The Double-Edged Sword of the Evidence-Based Medicine Renaissance

July 9, 2014

JH1A meeting involving critics and proponents of Evidence-Based Medicine (EBM) took place in September 2013 to discuss how to overcome current problems with EBM. Led by Trish Greenhalgh, the meeting attendees wrote an editorial that was published last week in the BMJ. The article, “Evidence based medicine: a movement in crisis?” argues that the many benefits of EBM have too often been obscured by undesirable and often unintended consequences including:

 

  1. Misappropriation of EBM by vested interests. These interests are often commercial but also include managers who use guidelines to control practitioners. Ironically while these guidelines are touted as ‘evidence-based’ they often lack a sound evidence-base.
  2. An unmanageable volume of evidence being produced
  3. Statistically significant but clinically irrelevant benefits being exaggerated in large trials and systematic reviews that report relative rather than absolute effects.
  4. Evidence being produced that is unsuitable for clinical practice, where patients often present with a complex mix of psychological, physiological, and social problems as well as other comorbidities.

The BMJ editorial has been a real hit, with thousands of views and downloads, as well as over 30 rapid responses. There is clearly a thirst for a renewed and refreshed version of EBM that helps achieve EBM’s stated aims.

The success of the editorial, however, is a double-edged sword. Complementary and alternative practitioners like the editorial because they can use it to point out that conventional medicine is not based on (good) evidence. Commercial interests will use it to undermine evidence suggesting their treatments don’t work. And without Herculean efforts (that go far beyond writing a beautiful article) the tide of the growing number of publications will not be stemmed. Meanwhile, the central and simple message of EBM, namely that best research evidence needs to be combined with patient values and circumstances, along with practitioner expertise, threatens to get buried under a mass of nebulous and heterogeneous critique. This will take us further away, and not closer to out goal of using best evidence to improve patient care.

The success of the renaissance depends on setting up and acting on an agenda that reinstates the core values of EBM so that patients benefit. This is just one of the aims of the 2015 Evidence Live Conference. Our interests as clinicians, policy makers, researchers, and (potential) patients are at stake!

Jeremy Howick

About Jeremy Howick

Jeremy is a funded postdoctoral research fellow at the CEBM. Jeremy's research draws on his interdisciplinary training of science and clinical epidemiologist. Research interests include the nature of 'placebos' and whether their use is ethical in clinical practice and clinical trials, the role of 'mechanistic reasoning' as evidence for efficacy and effectiveness for medical and social policy interventions. CEBM and Postgraduate Programme in EBHC tutor, Jeremy is also the author of The Philosophy of Evidence-based Medicine.

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