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The basic concept of evidence-based medicine proposes to make health related decisions based on a synthesis of internal and external evidence. Internal evidence is composed of knowledge acquired through formal education and training, general experience accumulated from daily practice, and specific experience gained from an individual clinician-patient relationship. External evidence is accessible information from research. It is the explicit use of valid external evidence (eg, randomised controlled trials) combined with the prevailing internal evidence that defines a clinical decision as “evidence-based.” To realise this concept in day to day clinical practice, the Evidence-Based Medicine Working Group proposed a 5 step strategy,1 corresponding to step 1 and steps 3 to 6 shown in the left hand column of the table.
In teaching this 5 step approach, we encountered several difficulties. We noticed a growing hesitance to accept this strategy as students advanced in their medical training. In the presence of well established methods of treatment or …