Dear Editor,

Different individuals have adapted and adopted the principles of EBM to different degrees and in vastly different ways [1]. There is yet another approach to EBM, which goes back a long way in terms of verbal justification on ward rounds but which has not been put in writing and taught in that way until recently [2]. It involves specifying the 'evidence' obtained from the patient that was used for each diagnosis and decision.

Instead of simply listing diagnoses and actions after the history and examination, the 'patient's evidence' for each diagnosis can be placed in parentheses after each diagnosis (e.g. "Diagnosis 1: Acute bronchitis [Cough with yellow sputum for 5 days, sweats, no wheeze, no crackles on 20/11/11, all findings resolved by 25/11/11]". After each treatment or test, the diagnostic indication is placed in parentheses (e.g. "Amoxicillin 250mg tds for 5 days for diagnosis 1". The Oxford Handbook of Clinical Diagnosis [2] provides thousands of such examples for students and young doctors and suggests different formats for presenting the 'patient's evidence'.

Many 'problem oriented' computer systems allow these links to be made automatically for each episode of care. If the patient has many diagnoses then they can all be listed with their 'diagnostic evidence' and management [2]. These can be updated (ideally automatically by computer) after each clinical episode in hospital and general practice.

When 'transparent evidence-based summaries' of this kind were written on a cohort of 76 patients admitted to a hospital under my care, an audit showed that 45 (59.2%) of patients went home within 3 days compared with 161 out of 376 (42.8%) patients going home within 3 days when such summaries were not written on admission (a difference of 16.4%, P= 0.008). This appeared to happen because the nurses and doctors taking over care could understand what had been done quickly and easily and continue the care or change it if necessary without delay.

This approach of linking in writing individual patients' findings to diagnoses and management for patients and others to read can be termed 'transparent medicine'. When the patient's findings match those in evidence-based guidelines (or a supporting publication discovered during or after a ward round) then the process can be described as 'transparent EBM'. I doubt whether anyone would argue with this way of practising medicine, which combines written transparency with EBM.

If the public become widely aware of this approach, it might become ethically unjustifiable to practice 'non-transparent EBM' unless some RCT showed that non-transparent EBM was as safe, efficient and effective as 'transparent EBM'!

References

1. Glasziou P. Editorial: What is EBM? Evid. Based Med. 2011 16:129- 130; doi:10.1136/ebm-2011-100099

2. Llewelyn H, Ang HA, Lewis K, et al. The Oxford Handbook of Clinical Diagnosis, 2nd ed. Oxford University Press, Oxford 2009.

Conflict of Interest:

None declared