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General medicine
The need for clinical judgement in the application of evidence-based medicine
  1. J. David Spence
  1. Stroke Prevention and Atherosclerosis Research Centre, 1400 Western Road, London, ON N6G 2V4, Canada
  1. Correspondence to Professor J. David Spence, Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, ON, N6G 2V4, Canada; dspence{at}robarts.ca

Abstract

Background Evidence-based medicine (EBM) has no doubt resulted in great improvements in the practice of medicine. However, there are problems with overly zealous application of EBM, that for some amounts to religious practice. When good evidence exists, it should guide therapeutic and diagnostic choices. However, when evidence is lacking for a given patient, medicine is best practised by extrapolation from available evidence, interpreted in the light of the pathophysiology of the condition under consideration, and effects of various therapies in relation to that pathophysiology.

Objective To assess ways in which the unthinking application of EBM can go wrong; these include withholding therapy in patients whose subgroup was excluded from clinical trials, blind acceptance of the numbers, reliance on studies with crucial design flaws and reliance on intention-to-treat analysis when it is not appropriate.

Study selection Examples assessed included withholding cholesterol-lowering therapy in the elderly, not using B-vitamin therapy for stroke prevention, not using revascularisation for true renovascular hypertension and avoiding statin therapy for fear of intracerebral haemorrhage.

Findings Zealous application of EBM is often inappropriate.

Conclusions In some instances, when there is a lack of evidence, or faulty interpretation of the evidence, clinical judgement should inform the application of EBM.

  • hypertension
  • lipid disorders
  • geriatric medicine
  • stroke medicine
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Footnotes

  • Contributors JDS wrote this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests JDS is a consultant to Amgen and Orphan Technologies, an officer of Vascularis Inc., and has received lecture fees from Pfizer and Bristol Myers Squibb.

  • Patient and public involvement statement Not applicable

  • Patient consent for publication Not applicable.

  • Ethics approval Not applicable

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

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