Criticisms of Evidence-Based Medicine

“Evidence-Based Medicine tells us to use only evidence from clinical trials and high quality observational studies in making clinical decisions. That evidence is statistical, comprising summary data (e.g. averages) from large groups. Whereas clinical decisions concern individuals and their particular circumstances. So, Evidence-Based Medicine cannot after all be a correct account of how doctors should make clinical decisions.” Is this a reasonable criticism of Evidence-Based Medicine?

Introduction

This essay aims to evaluate the criticism of Evidence-Based Medicine (EBM) mentioned above in order to determine whether using EBM is satisfactory in order to make clinical decisions. In this essay I will define EMB, and explain some of its advantages and disadvantages.

What is Evidence-Based Medicine and how is it applied?

Evidence-Based Medicine is a method of clinical practice that aims to use the expertise of clinicians and best available evidence in order to treat patients while also adhering to their values. ^[1}Sackett gives the definition as “Evidence based medicine (EBM) is the conscientious, explicit, judicious and reasonable use of modern, best evidence in making decisions about the care of individual patients”^[2]

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The primary aim of EBM is to use the strongest evidence based on the `hierarchy of evidence` ^{[3] [4]} by way of Systematic Review of Randomised Controlled trials (RCTs). The evidence is then used as a guide for clinical professionals to provide safe, cost-effective and efficient care plans by improving diagnostic accuracy and placing an emphasis on prognostic markers. ^[5]

The application of EBM can be broken down into 4 steps ^[6]:

• Establishing an understanding of the clinical scenario presented – Generally this is achieved by running relevant diagnostic tests, asking questions and observation.
• Search and Appraisal – The clinician will search for relevant articles pertaining to the scenario, within a certain timeframe through use of key terms. The articles found are peer-reviewed by other clinicians in order to determine the best course of action.
• Application of Results – the use of the information collected to treat patients.
• Evaluation – The process is evaluated in order to establish whether the available information was able to fulfil the necessary criteria to obtain a favourable outcome.

The EBM Debate

In Favour of the Claim:

It can be argued that EBM places too much emphasis on following a step-by-step algorithm ^[7]. This could hamper the development of the clinical expertise of junior clinicians as they may become too machinelike in their approach, resulting in a lack of care towards the patient’s needs and values. This may lead to conflicts of interest between the patient and the care team, overall patient satisfaction and a decrease in working efficiency, which could prove fatal in those with acute illness.

Furthermore EBM may not be the best option for those suffering from multimoribidities or comorbidities ^[7]. This is due to the fact that using clinical evidence to control one disease may lead to the worsening of, or even directly cause another disease. This also means that it is more difficult to find articles regarding the specific morbidities pertaining to the patient’s case due to fewer available articles, and even when found, the relevant application of the article may affect the patient differently than what was predicted by the evidence. In this case EBM may prove more detrimental to the overall wellbeing of the patient than beneficial.

Additionally it can be argued that there is too large a volume of evidence offered when practicing EBM ^[7]. This may result in the consideration of too much evidence by clinicians when coming up with a plan of action, leading to unnecessary time consumption and therefore inefficiency. This may lead to further issues as the smallest of delays could prove fatal when treating acutely unwell patients. 

Against the Claim:

EBM uses modern clinical evidence available, alongside clinical expertise gained by experience within the field in order to provide the clinician with an effective method of obtaining a precise diagnosis, and therefore being able to establish a course of action (i.e. treatment, surgery etc.) that has yielded positive results in similar cases previously. Additionally, patient values and morals are adhered to throughout the process via the clinicians expertise throughout the process of gaining an understanding of the situation and responding effectively. A combination of these two ideas allows for an effective treatment being delivered to the patient, while also catering for the needs, values and morals of the patient as an individual ^[2].  Additionally, using presented research means the clinician can make a judgement on whether the treatment proposed by the research is safe for their own scenario. This is because the research EBM provides is peer-evaluated and unbiased – having been subject to meta-analyses. Effectively, the clinician is implementing the known, most effective treatment observed in the treatment of cases similar to their own. Without EBM, the clinician may have to resort to trial and error to yield positive effects in their patient, which may result in the patient being subject to unnecessary harm.

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Furthermore, the criticism implies that EBM diverges from the use of a patient-centred approach when in dealing with clinical cases, and that patients are seen as more of a statistic as opposed to an individual. However, EBM is used alongside the clinician’s expertise and patient values and wishes. EBM uses clinical evidence to enhance patient safety and efficacy of treatment in order to provide the optimal result for the patient. Therefore, in most cases, the treatment of patients still caters for their individual circumstances and wishes.

Conclusion

To conclude, the criticism of EBM is partially correct in that it uses summary data from large groups in order to help determine the best course of action. However it does not take into account the fact that the evidence presented throughout the process of implementing EBM is subject to the expertise of the clinician and peer-evaluation. Therefore the evidence is used in order to determine the correct treatment plan for a particular patient by their care team, having taken into account the patients individual circumstances, needs, and values. EBM may be limited and flawed in many ways, the treatment of multimorbidities being a key example in this case, but despite this it offers a method to effectively treat patients using methods known to be safe, all the while allowing for the patient’s needs to be catered for by the care team. Therefore, despite its limitations it provides an efficient method for clinicians to assess and treat those under their care.

Bibliography

[1] Masic I, Miokovic M, Muhamedagic B. Evidence based medicine–new approaches and challenges. Acta Informatica Medica. 2008;16(4):219. [Cited 26 February 2019]

[2] Sackett DL, Rosenberg WM, Gray JM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. [Cited 26 February 2019] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3789163/