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"It is astonishing with how little
reading a doctor may practice medicine, but it is not astonishing, how
badly he may do it"
- Butler, "Equanimitas",
1901
As defined by the Centre
for Evidence-Based Medicine at the University of Oxford, "Evidence-based
medicine" (EBM) is the conscientious, explicit and judicious use of current
best evidence in making decisions about the care of individual patients."
The Evidence
Based Medicine Working Group at McMaster University, Canada, describes
EBM as "An approach to health care practice in which the clinician is
aware of the evidence in support of his/her clinical practice, and the
strength of that evidence."
The purpose of EBM is to apply the results
of quality medical research to the provision of health care, to improve
the quality of patient care, outcomes of care and the cost-effectiveness
of care.
The University
of Alberta describes the practice of evidence based medicine as divided
into the following components:
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Identifying a problem or area of uncertainty
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Formulating a relevant, focused, clinically
important question that is likely to be answered
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Finding and appraising the evidence
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Assessing the clinical importance of the evidence
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Assessing the clinical applicability of any
recommendations or conclusions
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Deciding whether or not to act on the evidence
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Assessing the outcomes of your actions
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Summarizing and storing records for future
reference (generally in the form of "systematic reviews")
According to the "Evidence
Based Medicine Course" from SUNY-Brooklyn, there are five factors that
go into making a medical decision:
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The patient's situation
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The patient's desires and values
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The doctor's values
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The doctor's experience
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Evidence from research
Medical decision-making is thus a complex
process. Traditional medical decision-making has focused on the first four
factors, emphasizing the experience of the individual physician or that
of a recognized "expert," utilizing the evidence from medical research
in a relatively minor way. This was largely because quality medical research
relevant to patient care was rare, and when it did exist it was difficult
to find and evaluate. With the recent emphasis on cost-effectiveness, the
easy access to medical literature databases such as MEDLINE and the growth
of the Web, practicing based on EBM has become a very real possibility.
EBM only addresses the fifth factor and
is therefore only a part of the overall medical decision-making process,
albeit a very important part. Evidence may not be strictly applicable to
any particular patient, given differences in age, coexisting medical conditions,
etc., but must be applied in the context of the other elements of a particular
patient's situation.
The Dark Side of EBM
There is, as yet, no evidence that EBM
actually improves patient care (see The
effects of clinical practice guidelines on patient outcomes in primary
care: a systematic review). It seems logical, however, that using the
demonstrated best science should improve patient care (and, yes,
this is not good EBM thinking).
You will also notice that even different
EBM-based systematic reviews can reach opposite conclusions, as on our
Sinusitis
and Asthma Web pages. In this situation, no solid
recommendations can be derived, and we must fall back on "clinical judgment."
Rev. 7/5/99
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