In the absence of evidence…
Posted on November 25, 2013 by Alice Buchan
Whilst evidence-based practice is often held up as the aim for all practice, it’s important to accept that not all practice is evidence-based. This often brings up the alternatives to EBM .
I encountered this on a recent clinical attachment, where many treatments were used on the basis that patients given them seem to get better, but on the basis of relatively little empirical evidence. I saw patients with bone infection (osteomyelitis), and after finishing the attachment, I looked for evidence, and found this Cochrane review . As I’d been told, most of the trials were done some time ago, and very few antibiotics had been specifically licensed for osteomyelitis – it was often an off-label use.
During my next attachment in general practice, I again encountered a lack of evidence-based medicine. This time, the reason I was given was not one of a lack of evidence, but of a lack of relevance – the general practitioner with whom I spoke described the elderly patients he saw – and that due to the combination of age and multiple comorbidities, there wasn’t any relevant evidence, as these patients were frequently excluded from clinical trials. In one sense, there is a need for evidence about how to manage these patients, given the ageing population in the UK and much of the developed world. After a bit more thought, I remembered the following definition of evidence-based medicine, “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”  Although it may be challenging to apply the existing evidence to complex patients and their needs, this made me think that evidence-based medicine is not just about applying a systematic review letter for letter – but that the ‘art’ of evidence-based medicine is in applying the science.
Essentially, systematic reviews can only cover the literature that’s out there – hopefully one purpose is to point out evidence gaps, and to help direct new research into developing areas. The people I’ve met who displayed a greater or lesser degree of skepticism towards EBM have made me think about it more, and given me an appreciation of how wide the scope of EBM can be.
 Isaacs D, Fitzgerald D. Seven alternatives to evidence-based medicine. BMJ 1999;319:1618 http://www.bmj.com/content/319/7225/1618
 Conterno LO, Turchi MD. Antibiotics for treating chronic osteomyelitis in adults. Cochrane Database Syst Rev 2013:CD004439
 Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2