“How do you feel about Evidence-Based Medicine?”

That was the question asked on a Medscape Connect discussion

I did a double-take. How do you feel? Could anybody object to the idea of basing treatments on evidence? The doctor who started the discussion asked:

Besides using EBM, a lot of my prescribing comes from anecdotal experience and intuition. How about you? Where do you get your information from that you use to treat your patients? Do you always ascribe to EBM, or do you deviate from it with certain medical conditions/patients?

I had naively thought that my profession uniformly embraced EBM. How could they not? The commenters broke my bubble big-time. Some of them summarily reject EBM… although it appears that what they are rejecting is not what I understand EBM to mean.

Note: I have excerpted the following quotations from the website, preserving the errors.

Some typical comments

• EBM is touted by ivory-tower bozos
• EBM is a pile of data-computer generated. You do not know which data are true or false.
• The science that we push has money attached to it.
• only 15% of what we do has any evidence base.
• I would like EBM better if it actually worked
• EBM: the biggest smoke screen in medicine
• Much of the “evidence” today is fabricated and doctored by Big Pharma
• hard working physicians are screwed from all directions even from statisticians who sit on rear end all day talking to computers and have all the time to pontificate without sweating looking after a dying patient or taking care of a bleeder that wont quit!
• Find a paper that says one thing, and I will find another that refutes
• Experience trumps EBM
• I see EBM as a way of “dumbing down” medicine to allow NP’s to try to practice medicine
• Allopathic medicine doesn’t have a monopoly on knowledge
• EBM is code for rationing and cookbook medicine such that experience doesn’t matter.
• it drives physicians to treat the diagnosis instead of the patient (the underlying flawed premise of EBM)
• In this system, how are we any different than a really smart computer
• It’s become the new religion.
• EBMs come from Committees.
• EBM is a “cookbook”. One size fits all. Experience and years of training does not matter
• With regard to meningitis vacccine, now that we are vaccinating everyone, it is less likely that people will look for a better way to prevent full blown meningococcemia
• EBM is statistics. Nothing else
• I use EBM as a guideline, but sometimes they fly in the face of my own experiences. As the punchline in an old joke, “Are you going to believe me or your lying eyes?” There is validity in experience.
•  THE INSURANCE COMPANIES PUSHED “EVIDENCE BASED MEDICINE” ON US!
• there is actually NO EVIDENCE that a practice based on so called EMB is effective or even relevant to real patients.
• I just love it when I get a note from an RN questioning my prescription and citing “Evidence Based Medicine”
• Intuition based medicine, like art, is always about a century ahead of science.
• “Evidence based medicine” is a form of doublespeak. It restricts recommendations to those proven in clinical trials, which don’t exist for most clinical situations
• EVERY ten years the Literature changes!!! EBM today is the quackery of tomorrow
• As long as drug companies own the experts and fund the vast majority of studies AND have the right to publish the findings or not as they see fit we will NEVER have fully reliable evidence… therefore evidence based medicine might well be WRONG medicine.

Keep in mind that these are not clueless celebrities, anti-vax mommies, or crank CAMsters. These are mainstream medical doctors. I weep!

Some of their less irrational objections (with my comments)

• Evidence from a trial with selected patients doesn’t necessarily apply to individuals in your office. (True. That’s where judgment and common sense come in. The trick is to not blindly follow anything labeled “evidence” but to consider all applicable factors and apply available evidence rationally.)
• Early adoption of EB treatments superseded by new data. (New data… isn’t that a good thing? Meanwhile, we can’t just do nothing while we are waiting for better data.)
• EBM gives us a cookbook. No progress was ever made by following a cookbook. (EBM was never intended to be a cookbook. We don’t follow a recipe, but apply available knowledge to individual patients.)
• I am not enthralled with EBM used by committee/hospital edict. (Me either. Who loves committees? That’s not the way it’s supposed to work).
• population studies with correlations are helpful but can never substitute for scientific, logical reasoning applied to the individual patient in question. (And they were never intended to substitute; they are intended to inform.)
• we’re supposed to turn in our fellow physicians who over-test or over-prescribe based upon “Evidence based Guidelines” (EBM is not Big Brother. Is this just paranoia, or have physicians actually been “turned in” or disciplined for not following these guidelines?)
• what I fear is rigidly taking the conclusions of a research study, … and FORCING physicians to do things that way. (I fear that too. It shouldn’t happen.)

There were a few more rational comments:

• I cannot comprehend what the alternative to EBM would be.
• It’s really just a label for “good medicine”
• there can be no doubt that our individual clinical experience is biased.
• we are all practicing EMB all the time but are being fed a brand of EMB with which we are not always comfortable (SBM is not comfortable with the current brand of EBMeither).
• Are we reverting to the Dark Ages?
• EBM should be used as a tool in the decision making process, but should not be deferred to in place of independent thinking nor considered a gold standard not to be deviated from.
• there is NO better alternative.
• EBM is a well-meaning and useful concept if tempered with judgment and judicious application. My challenge with it is that it has been turned into a religion, and we physicians are supposed to worship at its alter without the addition of any critical thinking.
• Evidence medicine implies that the studies have been peer reviewed and meet rigid criteria regarding study design and conclusions. It should not mean that small, poorly designed studies with unsupported conclusions are cited as part of EBMrecommendation.
• simply saying “I know what I know” and practicing anecdotal medicine by it self is simply dangerous

One commenter provided a link to SBM and called us “the militant wing of the EBMmovement.” Kind of ironic when we established the blog as a protest against the flaws inEBM.

Conclusion

Most people would agree that medicine should be based on evidence and on science whenever possible. Good medical practice is not an “art” but an applied science that takes all available knowledge into consideration and applies it to the individual patient using careful judgment, compassion, and common sense. EBM is a worthy goal; but as currently implemented, it has fallen short of its potential. We on SBM see it as neglecting basic science, prior plausibility, and common sense. Others apparently see it as a dogmatic institutionalized draconian interference with practitioner autonomy. Incredibly, some scientifically educated medical school graduates still see evidence as inferior to intuition and experience: those are the ones who give me chills.

^{This article was originally published in the Science-Based Medicine blog.}