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Decoding 'evidence-based medicine' for providers

MDlinx Jan 05, 2024

Is "evidence-based medicine" really evidence-based? It depends on who you ask. The term is commonly used to justify certain protocols and guidelines. However, plenty of research is still up for debate.

Evidence-based medicine is currently considered the gold standard for clinical decision-making. It’s rooted in combining the best available evidence with clinical expertise and patient values. But the goal of truly evidence-based medicine may not be as achievable as it sounds. Here’s why.


What does 'evidence-based' really mean?


The term evidence-based medicine means guiding care decisions based on a rigorous review of the research and extrapolating the data to real-world patients. During the 1980s, evidence-based medicine emerged from the work of clinical epidemiologists in Canada, led by the American-born physician Dr. David Sackett.

Thoma A, Eaves FF. A brief history of evidence-based medicine (EBM) and the contributions of Dr David Sackett. Aesthet Surg J. 2015;35(8):NP261–NP263.


Here are the five basic steps of evidence-based practice:

Tenny S, Varacallo M. Evidence Based Medicine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; October 24, 2022.


  1. Defining a clinical question

  2. Finding the best evidence

  3. Critically evaluating the evidence

  4. Applying the evidence to real-world scenarios

  5. Observing the outcomes


Practitioners are expected to stay on the cutting edge of research and weigh the evidence found in the medical literature by considering the strength of the study designs. Large meta-analyses that evaluate randomized controlled trials (RCTs) are considered top tier, followed by singular RCTs, non-RCTs, cohort studies, case studies, and expert opinions.

After surveying the evidence, clinicians determine how the available research applies to their patients. While providers make recommendations, they must also respect patient values and desires, even if these contradict the evidence supporting their recommended approach. Examples include patients’ choosing to forgo aggressive treatments to preserve quality of life.


When information evolves (or isn’t there)


The dynamic nature of medical science often puts evidence-based practice into question.

As new research emerges, it is not uncommon for previously established protocols to be reconsidered, leading to shifts in the clinical guidelines. The best physicians are knowledgeable about the evidence but flexible and open to change. 

In addition, physicians often face gray areas where high-quality evidence is lacking. Despite good intentions, evidence-based medicine isn’t possible in every case—such as when the circumstances are nuanced or the research simply isn’t there.


What about clinical judgment and expertise?


Not only do medical findings change over time, but some patients don’t fit into the neat categories documented in studies. In such instances, clinical judgment and shared decision-making with patients become paramount to navigating the complexities of care.

Providers must understand that research has strengths and limitations. While evidence may point to a particular intervention, there’s no substitute for clinical experience and intuition. 


Collaborating with specialists and making educated guesses are part of the uncomfortable learning curve to becoming a skilled provider.


Evidence under the influence


Another factor that muddies the pursuit of evidence-based care is the impact of industry-sponsored research. It’s no secret that pharmaceutical and medical device companies play a significant role in funding clinical trials—inevitably, this system can introduce biases. The pharmaceutical industry’s obligation to appease shareholders encourages “public relations propaganda over scientific integrity,” according an opinion paper published in the British Medical Journal.

Jureidini J, McHenry LB. The illusion of evidence based medicine. BMJ. 2022;376:o702.


Corporate interests have also infiltrated academia, tainting what was once hailed as an ethical and neutral space for scientific pursuit. Several points of influence, from the development of medical educational materials to the publishing of journal articles, have at times led to unhealthy relationships between university departments and for-profit companies.

As a result, today’s physicians must stay on guard to critically evaluate the sources of evidence and consider potential conflicts of interest. Even Dr. Sackett believed that the truth can only be found in randomized trials when they are feasible and they avoid the influence of bias. But unfortunately, for busy providers, sorting out the truth in the current research environment is often easier said than done.

What this means for you

In the quest for optimal patient care, physicians should be cautious about the concept of evidence-based medicine. Recognizing the evolving nature of medical knowledge, the potential influence of industry, and the irreplaceable need for clinical judgment is essential for high-quality healthcare. Ultimately, the art of medicine is constructed on a mixed foundation of evidence, reality, and humanity.


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