Evidence Based Medicine – Good, Bad, and Ugly
Evidence Based Medicine, or EBM, is the use of the best available medical science to guide decision making in healthcare. The modern day creator/proponent of the concept of EBM[1, 2], Dr. Sackett, intended and described the use of not only the very best quality research studies, but also other research, expert opinion, the experience of the healthcare provider, and values of the patient, as guidelines. The combination of the use of this “best evidence” and shared provider / patient decision-making is known as evidence based practice (EBP), and is the goal of most healthcare practitioners.
Unfortunately, Evidence Based Medicine is occasionally used in very restrictive ways (i.e. looking only at randomized control trials, RCTs, or systematic reviews) to make policy and guidelines decisions. This has been seen, on occasion, with regional Medicare, Workers’ Compensation, and some other insurance carriers that have limited patient’s access to certain procedures, imaging or medications based on a biased and narrow look at the research literature. The best policy decisions, when viewed with the balanced goals of patient access to appropriate care AND providing care with known “value”, are based on a “best-evidence” approach, as described above.
R. Scott Braithwaite’s recent opinion piece, “EBM’s Six Dangerous Words” , is a wise and pragmatic look at the darker side of evidence-based medicine (EBM). He opines that the phrase “there is no evidence to suggest…” can be dangerous, and “may inhibit shared decision making and may even be corrosive to patient-centered care.” He sites the tongue-in-cheek, but true example of: “There is no evidence to suggest that looking both ways before crossing a street compared to not looking both ways reduces pedestrian fatalities.” Although silly, it is exactly this type of statement that can be used to eliminate care access for certain procedures or care pathways. Braithwaite suggests that academic physicians and EBM practitioners instead use phrases such as: 1)”scientific evidence is inconclusive, and we don’t know what is best”, 2)”scientific evidence is inconclusive, but my experience or other knowledge suggests X”, 3)”this has been proven to have no benefit”, or 4)”this is a close call, with risks exceeding benefits for some patients but not for others.”
The goal should be patient-centered decision making and the formation of medical policies based on the best available evidence and designed with the best interest of patients AND the sustainability of the healthcare system in mind.
A very important tool being developed and used by important spine societies such as the International Spine Intervention Society (ISIS) and North American Spine Society (NASS) is the creation of Appropriate Use Criteria (AUC). AUC are developed in order to define areas of appropriate use, along with identifying potential overuse and underuse of procedures. This involves the integration of the best available scientific evidence with the clinical judgment of experts. See the ISIS web site, AUC section, for further details.
1. Sackett, D.L., Evidence-based medicine. Spine (Phila Pa 1976), 1998. 23(10): p. 1085-6.
2. Sackett, D.L., et al., Evidence based medicine: what it is and what it isn’t. BMJ, 1996. 312(7023): p. 71-2.
3. Braithwaite, R.S., A piece of my mind. EBM’s six dangerous words. JAMA, 2013. 310(20): p. 2149-50.