A categorization and analysis of the criticisms of Evidence-Based Medicine
Introduction
Evidence-Based Medicine (EBM) is a tool used to evaluate health care information and is promoted by its adherents as the preferred means to select and incorporate health care research into the practice of patient care [1]. Medical informatics and EBM are closely associated [2], [3]. EBM is an increasingly popular usage model for information within medical informatics [4], and like any usage model, places substantial requirements and limitations on any information system designed to support it. Therefore, it is essential that medical informaticians are familiar with the principles, major issues, criticisms, and limitations associated with the theory and practice of EBM in order to achieve their goal of effectively using and managing health care information.
The initial conception for what would later become known as Evidence-Based Medicine, was originated by clinical epidemiologists at McMaster University in Canada [1]. The core concepts of EBM are rooted in work done by these epidemiologists during the 1970s and 1980s applying the principles of epidemiology to the practice of patient care. This work was motivated, in part, as a response to the accusations made by Archibald Cochrane in his book, Effectiveness and Efficiency, which Hill describes as a “a biting scientific critique of medical practice”. In it, Cochrane accuses that many of the treatments, interventions, tests, and procedures used in medicine had no evidence to demonstrate their effectiveness, and may in fact be doing more harm than good [5].
Cochrane promoted the use of randomized controlled trials (RCTs) as the best means of demonstrating the efficacy of a therapy or an intervention, as well as the concept of “efficient health care”, that is, using the available healthcare resources to “maximize the delivery of effective interventions [5].” Cochrane’s ideas were adopted and expanded upon by David Sackett and others at McMaster University in the 1970s, which led to two major developments that form the core of EBM as it exists today: first was the establishment of the Cochrane Collaboration as an international group to “prepare, maintain, and disseminate up-to-date reviews of RCTs of health care [5]”; second was the idea that epidemiological principles should be used to incorporate the latest results of these reviews into the fundamentals of physician training and the practice of patient care. This second development later was given the name “Evidence-Based Medicine”.
The application of epidemiologic principles to the practice of patient care was first widely disseminated in the textbook Clinical Epidemiology, written by the McMaster epidemiologists Sackett, Haynes, and Tugwell and published in 1985 [6], [7]. This book discussed methods for applying epidemiological information as an aid in guiding clinical practice. But it did not coin or use the term “Evidence-Based Medicine [7], [8].”
The beginnings of EBM as a named movement (or “new paradigm” as some have called it) began in the early 1990s in Canada, the United Kingdom, and slightly later, in the United States [1]. The earliest recorded use of the term in an English medical journal appears to be in a 1991 editorial by Guyatt in the American College of Physicians Journal Club [9]. One of the first articles to popularize the concepts of EBM in the United States was published in JAMA in 1992 by the Evidence-Based Medicine Working Group [7]. Almost since its introduction, EBM has been an issue of polarized debate among physicians and other people involved in health care. In 1995 a new journal was founded, Evidence-Based Medicine, to further develop and disseminate the ideas of EBM and to aid doctors in putting its ideas into practice [10]. Davidoff, Haynes, Sackett, and Smith launched the journal with an announcement published as an editorial in the 29 April 1995 edition of the British Medical Journal (BMJ). The next several issues of the BMJ contain letters responding to the announcement and focusing on the failings of Evidence-Based Medicine [11], [12], [13].
Since then, over a hundred books and thousands of articles have been published applying, evaluating, debating, criticizing, and supporting EBM. Proponents continue to state that the goal of EBM is to save the practice of medicine from many of its major ills, including wide variations in clinical practice, use of unproven interventions, and failure to apply consistent practice guidelines. Opponents deny either the severity of these issues, or that EBM can adequately address them, and dismiss EBM on the grounds of many philosophical and practical flaws.
One recent essay by Straus and McAlister surveying the literature and categorizing criticisms on EBM grouped common criticisms into three categories: (1) limitations universal to the practice of medicine, (2) limitations unique to evidence-based medicine, and (3) misperceptions of Evidence-Based Medicine [14]. No categories specifically addressed flaws or omissions in the philosophical basis of EBM, and many practical issues, such as EBM requiring the expenditure of limited health care resources that may be needed elsewhere, were ignored or glossed over.
The Straus and McAlister paper placed as many issues into the “misperceptions of EBM” category as into the “limitations” categories, the implication being that an overwhelming number of the EBM critics simply do not understand EBM. Given that the pros and cons of EBM have been debated for over a decade, it is unlikely that the EBM critics have basic misunderstandings of the fundamental principles of EBM. It is more likely that Straus and McAlister’s choice of categories shows a strong pro-EBM bias and fails to elucidate the true nature of the issues.
With the discussion of EBM being dominated by strong supporters and opponents, it seems worthwhile to take a step back and attempt to evaluate EBM dispassionately and objectively. The goal of this paper is to categorize and evaluate the criticisms and limitations of EBM to gain a better understanding of the role EBM can most appropriately play in medical science and modern health care.
Section snippets
Operational definition of Evidence-Based Medicine
In order to evaluate the limitations and criticisms EBM it will be useful to provide a specific definition on which to base the analysis. The previously mentioned 1995 editorial in the British Medical Journal announcing the creation of the journal Evidence-Based Medicine gave this definition of EBM:
…evidence based medicine is rooted in five linked ideas: firstly, clinical decisions should be based on the best available scientific evidence; secondly, the clinical problem - rather than habits or
Criticisms and limitations of Evidence-Based Medicine
More than 10 years of debate and discussion about EBM have uncovered many areas of disagreement between EBM supporters and detractors, as well as many unanswered questions about the use and role of EBM in modern health care. Nevertheless, the debate tends to revolve around a small number of themes that will serve as useful foci for discussion.
Current criticisms and limitations of EBM can be grouped into five main themes:
- 1.
EBM is based on empiricism, misunderstands or misrepresents the philosophy
Conclusions
To some extent, the root of all of the issues with EBM, reflected in all of the themes, stems from the name “Evidence-Based Medicine” [1]. By declaring that medicine itself should be “evidence-based”, EBM advocates branded a specific clinical tool as superior and in opposition to the traditional, patient-optimized approach to the practice of clinical medicine.
This was unfortunate, because it started a decade-long debate about whether medicine should be ruled by “evidence” and what this would
Acknowledgements
The authors wish to thank Dr. Mark Helfand for his extensive comments and helpful review during the writing of this article. This work was supported by NIH Grant number 2 T15 LM07088-11 from the National Library of Medicine.
References (33)
- et al.
Standardization in health informatics in Canada
Int. J. Med. Inf.
(1998) Grey zones of clinical practice: some limits to Evidence-Based Medicine
Lancet
(1995)- et al.
A comparison of observational studies and randomized, controlled trials
Am. J. Ophthalmol.
(2000) - et al.
Why do nurses abuse patients? Reflections from South African obstetric services
Soc. Sci. Med.
(1998) What kind of evidence is it that Evidence-Based Medicine advocates want health care providers and consumers to pay attention to?
BMC Health Serv. Res.
(2002)Medical informatics: improving health care through information
JAMA
(2002)Data information and knowledge: the health informatics model and its role in evidence-based medicine
J. Eval. Clin. Pract.
(2002)Archie Cochrane and his legacy. An internal challenge to physicians’ autonomy?
J. Clin. Epidemiol.
(2000)- D.L. Sackett, R.B. Haynes, P. Tugwell, Clinical Epidemiology: A Basic Science for Clinical Medicine, first ed., Little...
- Evidence-Based Medicine, A new approach to teaching the practice of medicine, Evidence-Based Medicine Working Group,...
The rise and fall of EBM
QJM
Evidence-based medicine
ACP J Club
Evidence-Based Medicine
BMJ
Evidence-Based Medicine. Many questions cannot be answered by Evidence-Based Medicine
BMJ
Evidence-Based Medicine. No guidance is provided for situations for which evidence is lacking
BMJ
Evidence-Based Medicine. Rich sources of evidence are ignored
BMJ
Cited by (188)
Postulates of evidence-based medicine have transformed into myths
2024, Educacion MedicaRole of human epidemiology in risk assessment and management
2022, Present Knowledge in Food Safety: A Risk-Based Approach through the Food ChainBiomimicry of the flexor digitorum superficialis: Systematic literature review
2021, Hand Surgery and RehabilitationImplementation of algorithms in pattern & impression evidence: A responsible and practical roadmap
2021, Forensic Science International: SynergyCitation Excerpt :This was considered particularly important in situations where the context of an individual case is under-represented in the statistical data [56] and therefore insufficient to provide a meaningful contribution to the decision. Although EBM supporters recognize the value and necessity for individual judgment, it remained a point of debate as to how experience should be integrated with EBM evidence [56]. The EBM movement provides an important, and more recent, case-study illustrating the challenges with introducing algorithms into a domain that has traditionally been driven by human judgment.
Challenges and opportunities for Australian osteopathy: A qualitative study of the perceptions of registered osteopaths
2018, International Journal of Osteopathic Medicine