I firmly believe clinical practice should be based on the best scientific evidence. But how do you define best evidence? Evidence-based medicine (EBM) founders say “identifying the best evidence means using epidemiologic and biostatistical ways of thinking.”1Table 1
lists five reasons why this approach is scientifically unsound.
1Davidoff, F, Haynes, B, Sackett, D, et al (1995) Evidence based medicine.BMJ310,1085-10862Cook, DJ, Guyatt, GH, Laupacis, A, et al Clinical recommendations using levels of evidence for antithrombotic agents.Chest1995;108(4 Suppl),227S-230S3Sackett, DL, Straus, SE, Richardson, WS, et al Evidence-based medicine: how to practice and teach EBM 2nd ed.2000,108 Churchill Livingstone. Edinburgh, UK: 4Evidence-Based Medicine Working Group.. Evidence-based medicine: a new approach to teaching the practice of medicine.JAMA1992;268,2420-24255Linde, K, Clausius, N, Ramirez, G, et al Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials.Lancet1997;350,834-8436Tobin, MJ, Jubran, A Meta-analysis under the spotlight: focused on a meta-analysis of ventilator weaning.Crit Care Med2008;36,1-77Haack, S Defending science–within reason: between scientism and cynicism2007 Prometheus Books. New York, NY: 8Popper, K The logic of scientific discovery1958 Hutchison. London, UK: 9GRADE Working Group.. Grading quality of evidence and strength of recommendations.BMJ2004;328,1490-149410Ziman, J Real science: what it is, and what it means2000 Cambridge University Press. Cambridge, UK: 11Haynes, B What kind of evidence is it that evidence-based medicine advocates want health care providers and consumers to pay attention to?BMC Health Serv Res2002;2,1-712Guyatt, GH, Sackett, DL, Sinclair, JC, et al Users' guides to the medical literature: ix. A method for grading health care recommendations; Evidence-Based Medicine Working Group.JAMA1995;274,1800-180413Ely, EW, Meade, MO, Haponik, EF, et al Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: evidence-based clinical practice guidelines.Chest2001;120(6 Suppl),454S-463S14Ely, EW, Baker, AM, Dunagan, DP, et al Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously.N Engl J Med1996;335,1864-186915Pitt, B, Zannad, F, Remme, WJ, et al The effect of spironolactone on morbidity and mortality in patients with severe heart failure: randomized Aldactone Evaluation Study Investigators.N Engl J Med1999;341,709-71716Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee To Revise the 1995 Guidelines for the Evaluation and Management of Heart Failure): ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult, executive summary.Circulation2001;104,2996-300717Juurlink, DN, Mamdani, MM, Lee, DS, et al Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study.N Engl J Med2004;351,543-55118Sinuff, T, Cook, DJ, Randall, J, Allen, CJ Evaluation of a practice guideline for noninvasive positive-pressure ventilation for acute respiratory failure.Chest2003;123,2062-207319Hill, NS Practice guidelines for noninvasive positive-pressure ventilation: help or hindrance?Chest2003;123,1784-178620Straus, SE, McAlister, FA Evidence-based medicine: a commentary on common criticisms.Can Med Assoc J2000;163,837-841