Evidence based medicine—let it rest in peace

Oct 23, 2013

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I wrote an article just published in Clinics in Dermatology: Why we should let “evidence-based medicine” rest in peace [paywall].

The abstract is below. Will people let it RIP? No, because as Bruce Charlton has written, EBM is Zombie science. You cannot kill zombies, because they are dead already: they are the undead, they will not lie down.

Evidence-based medicine is a redundant term to the extent that doctors have always claimed they practiced medicine on the basis of evidence. They have, however, disagreed about what exactly constitutes legitimate evidence and how to synthesize the totality of evidence in a way that supports clinical action. Despite claims to the contrary, little progress has been made in solving this hard problem in any sort of formal way.

The reification of randomized clinical trials (RCTs) and the tight linkage of such evidence to the development of clinical guidelines have led to error. In part, this relates to statistical and funding issues, but it also reflects the fact that the clinical events that comprise RCTs are not isomorphic with most clinical practice. Two possible and partial solutions are proposed: (1) to test empirically in new patient populations whether guidelines have the desired effects and (2) to accept that a distributed ecosystem of opinion rather than a hierarchical or consensus model of truth might better underwrite good clinical practice.

Post by Jonathan Rees

Clinical academic and skin watcher at the University of Edinburgh

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