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Evidence-based medicine is a medical movement based upon the
application of the scientific method to the whole body of medical
practice, including long-established existing medical traditions that may never
have been subjected to systematic scrutiny. According to the Centre for Evidence-Based Medicine, "Evidence-based medicine is the conscientious,
explicit and judicious use of current best evidence in making decisions about the care of individual patients."
Overview
Using techniques from science, engineering and statistics, such as meta-analysis of the existing literature, risk-benefit analysis
and randomized controlled trials, it aims for
the ideal that all doctors should make "conscientious, explicit, and judicious use of current best evidence" in making
decisions about the care of individual patients.
Evidence-based medicine argues that it is impossible to use testimonials, hearsay and mystical arguments as proof because
observer bias distorts recollection.
Practising evidence-based medicine implies not only clinical expertise, but expertise in retrieving, interpreting, and
applying the results of scientific studies, and in communicating the risks and benefit of different courses of action to
patients.
For all its problems, evidence-based medicine has very successfully demoted the ex cathedra statement of the "medical
expert" to the least valid form of evidence — all experts must sprinkle their
pronouncements with references to the relevant literature.
History
Professor Archie Cochrane was a British medical researcher whose
book Effectiveness and Efficiency: Random Reflections on Health Services (1972) and subsequent advocacy caused
increasing acceptance of the evidence-based medicine concept. Cochrane's work was honoured through the naming of centres of
evidence-based medical research — Cochrane Centres — and an international organisation, the Cochrane Collaboration.
Criticism of evidence-based medicine
Critics of evidence-based medicine state that doctors were doing these things already, that good evidence is often deficient
in many areas, that lack of evidence and lack of benefit are not the same, and that the more data are pooled and aggregated the
more difficult it is to compare the patients in the studies with the patient in front of the doctor. In The limits of
evidence-based medicine ,
Tonelli argues that "the knowledge gained from clinical research does not directly answer the primary clinical question of what
is best for the patient at hand." Evidence-based medicine seems to them to discount the value of the case study.
The primary problem is that evidence-based medicine is most effective when testing the effectiveness of drugs and may not be appropriate for other forms of treatment, particularly those requiring the active
participation of the patient. Some treatments take a more holistic
approach, which may be difficult to fit into a testing model that assumes the patient is a passive object acted upon by the
treatment.
Critics also raise conflict of interest. Journals such
as the New England Journal of
Medicine, The Lancet, JAMA, and the
British Medical Journal have been unable to prevent
papers ghostwritten by pharmaceutical companies from being published. These same pharmaceutical companies are a primary source of
funding for medical and drug research. In some cases, doctors listed as authors on ghostwritten research papers did not review
the raw data, only tables compiled by a medical writing company. (See also Flanagin A, Carey LA, Fontanarosa PB:
Prevalence of articles with honorary authors and ghost authors in
peer-reviewed medical journals ; Larkin M: Whose article is it anyway? )
Some critics also claim that evidence-based medicine seems more concerned with the job security of researchers than with
solving health problems.
Long before evidence-based medicine came along, case studies were an
acceptable form of medical research. Case study methodology can be applied effectively to the study of men with chronic coronary
heart disease, for example. "Case study methodology can be used as a creative alternative to traditional approaches to
description, emphasizing the patient's perspective as being central to the process. Contemporary practitioners and researchers
have come to appreciate the subjective richness of patients recounting their experience and the meanings implicit in them to help
guide practice." ( Zucker, DM: Using Case Study Methodology in Nursing Research ) The importance of the individual patient in
the case study method runs counter to evidence-based medicine's emphasis on population evidence.
However, whereas is the past population trials have had to group patients according to very broad criteria such as age or
according to basic parameters such as blood pressure, with increasing access to comprehensive genetic and physiological testing
future trials may well be able to combine the best aspects of large scale epidemiology with the detailed investigation of
individual patients. That is, the trials will be of thousands of 'individuals' and the data provided by increasingly be more
relevant and more easily applied to the patient before the doctor
See also
External links
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