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Evidence-based medicine (EBM) is a juggernaut that has taken practitioners by storm. Over the last 20 years, my colleagues at McMaster University, as well as at other academic institutions, have spearheaded the EBM movement to the point where journal articles with “evidence-based” in the title are ubiquitous. While EBM is not perfect and is a continuing work in progress—qualitative levels of evidence seem to change definition regularly—the fundamental principles of EBM are unquestionably an advance in the management of patients.
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As a rule, physicians are dedicated to their patients and usually convinced that they deliver the best possible care. It is difficult to accept the possibility that our patients might not be getting optimal care because of our decision-making processes. For decades, the main teaching methods in medical schools consisted of non-interactive didactic teaching sessions and rounds with attending physicians and senior residents where each would try to “out anecdote” the other. These rounds usually created a competitive environment, in which the primary focus was placed on cases we had never seen before and would never see again. From these “canaries,” the words and experience of the senior attending, which were based on his “vast experience” of two or three patients, were gold nuggets. Nobody questioned, let alone challenged him. Over the last three or four decades, it has become clear that not everything in medicine is black or white and that disagreements among clinicians is quite common.
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So how do we reconcile the “If I say it, it must be true” or the disagreements? In retrospect, the answer was so simple and yet until recently, the technology did not exist to make the transformation to evidence-based medicine. Since one of the main purposes of publishing papers is the dissemination of information, it seems only logical to use the Internet to perform a literature review and see not only the experience of others, but also if any well-designed studies had been done addressing the issue. Unfortunately, in the early to mid 1980s, computers were slow and the internet was still in its infancy, and so performing literature reviews for every clinical question was highly impractical.
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Over the next 10 to 20 years remarkable advances have facilitated literature reviews and spawned a generation of practitioners who practice evidence-based medicine. The main advances included the vast expansion of the World Wide Web, the availability of portable and powerful computers to access the Internet, and the recognition that the uncritical acceptance of the professor's experience, while somewhat useful, was very limited and often wrong. In parallel, the National Library of Medicine simplified the performance of literature reviews within an enormous database and made it widely available and easily accessible.
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It is difficult to justify the “professor's experience” approach to clinical decision making while ignoring the vast amount of relevant literature that is accessible in a handheld device or laptop computer. The fundamental principles of EBM include an approach ...