Although Dr Upshur and Mr Tracy agree1 with us that the practice of medicine should be based on sound research, they argue that evidence-based medicine (EBM) is overrated because of vagueness and incompleteness; incongruence with the realities of family medicine; ubiquity and overexposure; and failure to meet its own standard. These arguments reflect their misunderstanding of what practising EBM is really about.2–4
However, the definition of EBM is clear.2–5 The practice of EBM aims to make high-quality clinical decisions taking into account the best available scientific evidence, clinical expertise, patients’ unique values and preferences, and clinical context and circumstances.
Dr Upshur and Mr Tracy suggest that the proposed structure of EBM (the “steps”)6 is irrelevant to family medicine. They possibly do not recall the rigid structure that clerks follow when performing their first case histories. Of course, with acquired expertise and experience, clinicians adapt the history-taking structure to individual patients, clinical situations, and contexts. The steps provide a framework—not a “cookbook”—of the key elements to take into account when making decisions together with patients.
The lack of medical research for many health problems and specific populations seen in family medicine does not preclude the practice of EBM. On the contrary, the EBM practitioner, knowing the state of the evidence, is able to share this information with the patient and together they can make informed decisions based on other grounds. In addition, the EBM practitioner understands that study results are estimates for the average patient, that these results have to be interpreted and applied as such, and that different results might be obtained in the future. Both sides have described and condemned the inappropriate use of the term EBM for monetary gain. More and better training of family physicians in EBM would enhance understanding of what EBM is truly about, help physicians to act as informed “consumers” of research results, and unmask individuals or organizations exploiting the term for profit.
Evidence-based medicine is not an “intervention,” but a framework integrating key elements of optimal practice in medicine: judicious use of best available scientific evidence, patient-centred care, and shared decision making.
Footnotes
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Competing interests
None declared
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These rebuttals are responses from the authors of the debates in the November issue (Can Fam Physician 2013;59:1160–3 [Eng], 1164–7 [Fr]).
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