Pro: should evidence-based medicine be used more in clinical practice?

The California Journal of Emergency Medicine VII:1, Jan-Mar, 2006 Page 13 PRO/CON Pro: Should Evidence-Based Medicine Be Used More in Clinical Practice? Chris Fee, MD Department of Emergency Medicine University of California, San Francisco San Francisco, California When first asked to write the pro side of this debate, I found myself enthusiastically accepting. After all, what possible argument could be found against implementing a more evidence-based approach to one’s clinical practice? Perhaps because of my fervent support of doing so, I found myself having trouble approaching this article. How can one write the pro side to a debate topic when the con side is so hard to envision? Perhaps we should begin with a seemingly simple question: what is evidence-based medicine (EBM)? The term “evidence-based medicine” originated at McMaster University in Canada and was first used in the medical literature in 1992. 1 The most commonly used definition is that put forth by the Centre for Evidence-Based Medicine at the University of Oxford. They state that EBM “is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” 2 Is this not what physicians have been doing for centuries? Does this imply that before the advent of Table. Grading system. 3 Grading of recommendations A: Supported by at least two level I investigations B: Supported by one level I investigation C: Supported by level II investigations only D: Supported by at least on level III investigation E: Supported by level IV or V evidence EBM medicine was unscientific? No. The primary impetus behind the creation of EBM as we now know it was to encourage physicians to improve the scientific basis of their clinical practice through teaching them to interpret the scientific literature in a critical and meaningful manner. Proponents of EBM state that “all medical action of diagnosis, prognosis, and therapy should rely on solid quantitative evidence-based on the best of clinical epidemiological research” and that “we should be cautious about actions that are only based on experience or extrapolation from basic science.” 1 This includes not only understanding how to interpret a particular study, but also understanding the hierarchy of the evidence, which is based on the methods used to collect it (with the randomized controlled trial (RCT) taking form as the penultimate study format for many clinical questions, and case reports and case series or other experiences based on small n constituting a research hypothesis, but not comprising definitive evidence in support of a hypothesis). It is worth noting here the emphasis on relying on the current “best” evidence. There are simply too many clinical questions and too many variables to control to realistically expect a RCT to be available to answer every clinically relevant issue. Many specialty societies have addressed this issue by grading recommendations and evidence within consensus statement guidelines (see table). 3 Detractors of the EBM movement often point out that everyone is already practicing this way or conversely that it is impossible to implement into practice. There is ample data to support the concept that a large portion of the medical profession fails to practice EBM. The high prevalence of practitioners continuing to prescribe antibiotics to patients presenting with upper respiratory infections is a case in point. Not only has this practice been shown to be ineffective, but there is growing concern that doing so plays a major role in the growing antibiotic resistance debacle we now face. Other examples include the poor adherence of physicians Grading of evidence I: Large, randomized trials with clear-cut results; low risk of false-positive (alpha) error or false-negative (beta) error II: Small, randomized trials with uncertain results; moderate-to-high risk of false-positive (alpha) and/or false-negative (beta) error III: Nonrandomized, contemporaneous controls IV: Nonrandomized, historical controls and expert opinion V: Case series, uncontrolled studies, and expert opinion