• DOI:10.1038/sc.2017.106
• Corpus ID: 4702224

Is evidence-based practice a sinking ship?

@article{Harvey2017IsEP,
  title={Is evidence-based practice a sinking ship?},
  author={Lisa A. Harvey},
  journal={Spinal Cord},
  year={2017},
  volume={55},
  pages={885-885}
}

• L. Harvey
• Published 1 October 2017
• Medicine
• Spinal Cord

Surely it is not the job of an editor to be directing readers to other journals! That would be like a radio broadcaster telling listeners to tune into another channel, or to a company director telling consumers to purchase another product. However, this Editorial is going to do just that. I am going to recommend that the readers of Spinal Cord peruse another journal: The Journal of Clinical Epidemiology. (Please don’t tell our publishers, this is between just you and me). The reason for directing you to this journal is because it has published a special issue in salute of David Sackett: the father of evidence-based practice (EBP), who died last year.1 This issue of The Journal of Clinical Epidemiology contains interesting and controversial papers about EBP. However, the paper which caught my eye was written by John Ioannidis. It is titled—“Hijacked evidence-based medicine: stay the course and throw the pirates overboard”.2 Who are the pirates that Ioannidis would have thrown overboard? More importantly, how are they hijacking EBP? Ioannidis argues that the ‘pirates’ are those who delight in finding any small nuance or deficiency in EBP that can be used to discredit the movement (to sink the ship of EBP). A common criticism is that EBP only cares about estimates of population-based averages and that these estimates are of little relevance because ‘we are all individuals’ (as so famously stated in one of the Monty Python comedies). This criticism always takes me by surprise because of course we and our patients are all individuals, and of course very few patients are going to behave like the population-based estimates EBP strives to provide: some will do better and others will do worse. Sackett never argued that we should only be driven by estimates of population-based averages. To the contrary, he was a strong advocate of the importance of combining this information with clinicians’ and patients’ perspectives, experiences and priorities. He defined EBP as ‘integrating individual clinical expertise with the best available external clinical evidence from systematic research’ (page 71).3 He was, nonetheless, a champion of the use of high quality external evidence to support clinical decision making. Sackett’s push for high quality external evidence was primarily based around the concern to avoid bias when assessing treatment effectiveness. That is why he advocated reliance on randomised controlled trials. In recent years randomised controlled trials have come under a sustained attack. The strongest attacks have been launched by those who are unhappy with the findings of clinical trials. When new treatments that initially looked promising, or when old treatments that we have all faithfully administered, fail to deliver, we tend to question the methodology rather than question the treatment. We criticise randomised controlled trials and EBP and search for other methodologies that are more likely to give us the answers we expect or want. Unfortunately, alternative methodologies are always inferior and vulnerable to bias. Others criticise EBP because it fails to quantify the possibility of harm, identify subgroups of responders, and individualise medicine. Ioannidis states that: