The thoughts expressed here come from the perspective of a practicing physician and have been mulled over and revised for many years. They were born out of a deep sense of disconnection between the practice of medicine and the medical literature. And a sense of dissociation between the way that medicine is actually practiced and the way it is apparently supposed to be practiced (according to the tenets of Evidence-Based Medicine).
Over the years, I have attended countless Journal Clubs, rounds, and various gatherings in which we discuss the surgical literature. I have read countless papers on topics related to my surgical specialty. The only truly memorable aspect of reviewing these papers is, in general, how remarkably forgettable the were. I cannot recall in the past 2 decades one time where colleagues generally agreed that a given study/paper was even good (let alone excellent), nor can I recall a time when I have been enlightened, illuminated or meaningfully instructed by an Evidence-Based analysis of a study. The usual way a Journal Club proceeds is that someone (usually a resident) provides a mind-numbinglingly boring synopsis of a paper. We then criticize the paper mercilessly and express our general incredulity that a journal would publish such a flawed study. And finally, we then proceed to exchange views about what we believe and do in our own practices. This is the part of Journal club that I find instructive and illuminating. I suspect that this experience will resonate with many physicians.
As all physicians know, EBM is supposed to represent judicious use of the best current evidence when making decisions about patient care. As Sacket wrote in 1996:
“Evidence based medicine is the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”
Sackett et al BMJ 1996: 312
On a theorectical level, Evidence-Based Medicine seems to make inherent sense: use the best evidence along with my clinical expertise, to treat patients. But on a practical level, EBM just doesn’t seem to work. There is a puzzling disconnect between the theory and practice of EBM. And if discussions with my colleagues are any indication, I know that many physicians harbour reservations about EBM, but are reluctant to speak about it. I think their reluctance to speak out about it occurs for three reasons. First, they are wary of being considered a luddite if they appear to be rejecting technological change. Second, they don’t fully understand why EBM doesn’t work and are therefore reluctant to speak out against it. And third, they are overwhelmed by the number of prominent people, institutions, and journals which endorse it fully. In this regard, there is certain certain amount social conformity and political correctness at play. I mean, to suggest that modern medical science could be so misguided is like arguing that the earth revolves around the sun, in the days prior to Copernicus and Galileo. It may be hard to believe, but there is considerable peer pressure to toe the line. I know…, because I toed the line for a long time. Questioning the validity of EBM nowadays is like questioning the authority of the Roman Catholic church prior to Luther. It is anathema.
This website is devoted to understanding the disconnect between the theory and practice of EBM and elucidating the shortcomings of EBM. To use some of EBM’s own vocabulary, the goal of this website is to encourage a “critical appraisal” of EBM.
This is not an entirely unique undertaking. There are actually many physicians who write critically about EBM. And I have learned much from them.