Hi Piersante,
     I will answer using a satire. Did anyone ever mention that EBM provides absolute answers or truth and nothing but truth? Answer is a big nooooooooooooo! However, EBM does makes an attempt to get closer to it. Nevertheless, opponents should be reminded of a beautiful piece published about 10 years ago in BMJ titled "Seven alternatives to evidence based medicine" by David Isaacs and Dominic Fitzgerald available at http://www.bmj.com/cgi/content/full/319/7225/1618 which clearly provides an alternative.

What I would emphasize med students about EBM is to change their learning paradigm. Think in terms of probability (EBM practitioners) rather than certainty (this is reserved for surgeons only). That is, be able to decipher evidence from propaganda. Have the skills to be smart consumers of research but not necessarily researchers. A questionable mind is what EBM should emphasize on creating.

Forget about EBM and lets continue the treatment given to King Charles II of England (blood letting, and gall baldder of Indian Goat) for Brain seizure.........No it is not available today and no prescription required.......so physicians would not like it as it is available freely to lay man (so can't be considered a treatment if it is lying around freely). But we can certainly do similar things even today..........give mammograms to all women starting at 18 years of age.....works in older women so starting early makes sense..........or may be put all diabetics on Avendia (I know it works, how it works...don't ask me)........or may be Blood glucose testing meter hooked to every diabetic (looks we are doing something....got to do something .......that temptation of doing good....wow!....feels a tleast for a bit like playing god when doing something ........can keep going on and on......

In summary.....Is EBM a perfect science......surely not.....but does it prompts you to make an effort to get at least closer to the truth...certainly....

Cheers and to the proponents of EBM......ignorance is indeed bliss. More you study..........you realize how little you know


Ambuj Kumar, MD, MPH

On Wed, Aug 18, 2010 at 7:56 PM, Piersante Sestini <[log in to unmask]> wrote:
 Lately, I have been involved in a couple of debates with critics of EBM.
http://chestjournal.chestpubs.org/content/135/1/245.1.full
http://www.ncbi.nlm.nih.gov/pubmed/20367853

The charge of my opponents was, basically, that EBM consists largely in the application of rigid rules (particularly about critical appraisal and hierarchies of evidence).
My understanding, however, is that those are not rules, but heuristics (rules of thumb) based of reasonable rational assumptions, while EBM consists in the systematic and judicious integration of expertise and data from clinical research to solve a patient's problem (which of course includes preferences and values), not in following rules.
Their rebuttal, is that they are taught and practiced as rules, so that to be an EBMer is  commonly presented as rule-following.
I am confused, as I have always considered EBM more as critical thinking and rule-breaking.
To consider checklists and hierarchies as prescriptive rules, rather than working aids, seems to me to be at odds with the foundations of EBM, since they are largely based on background information. It would sound like to make a clinical choice based only on data from pathophysiology.

So, my questions are:
How much is my view shared?
In your experience, how much of EBM curricula are dedicated to understanding the principles behind the heuristics, rather than teaching how to follow rules?

thanks,
Piersante Sestini



--
Ambuj Kumar, MD, MPH
727-481-2787