Message from the Director of the Center

 

The term "evidence-based medicine" was introduced in 1992 by Gordon Guyatt and colleagues at McMaster University, Canada, and its recognition spread rapidly to medical schools worldwide.

The article published in 1992, which introduced evidence-based medicine, was cited 13,000 times by 2004.

Evidence-based medicine is the wise, explicit, and judicious use of the best available evidence in making decisions about the care of individual patients. Evidence-based practice means integrating the personal clinical experience of the physician with the best available external clinical evidence derived from systematic research.

Individual clinical experience refers to the mastery and judgment that physicians acquire individually through their practice and experience. Increased experience is reflected in various ways, particularly in more effective and efficient diagnoses, as well as in the thoughtful identification and consideration of patient dilemmas, rights, and preferences in clinical decision-making regarding their care.

 

The best available external clinical evidence refers to clinical research, particularly patient-centered clinical trials, that demonstrates the accuracy and validity of diagnostic tests (including clinical examination), the strength of prognostic indicators, and the effectiveness and safety of therapeutic regimens, rehabilitation, and prevention strategies. External clinical evidence not only invalidates previously accepted diagnostic tests and treatments but also replaces them with newer, stronger, more accurate, effective, and safer alternatives.

 

 

 

Evidence-based medicine teaches us how to become proficient users of information. The need to learn evidence-based medicine skills arises because, firstly, medical information is vast and growing rapidly, and secondly, physicians have limited time to study. While information refreshes quickly, physicians cannot continue to use the same diagnostic and therapeutic methods they learned at graduation. What was once the preferred treatment for a condition may be proven ineffective or even harmful by newer studies. Studies have shown that to keep up with just 5% of medical information, one must study 20 journals weekly, which is virtually impossible.

Additionally, studies indicate that common continuing education programs have not been sufficiently effective, so there is a need to learn methods for lifelong learning.

Evidence-based medicine is also a form of critical thinking in medicine. Medical information comes with varying degrees of credibility, but physicians often lack the ability to critically evaluate information and distinguish credible sources from non-credible ones. Studies also show that physicians lack a clear understanding of terms used in articles, even though knowing these terms directly impacts clinical practice. Furthermore, regarding the latest books, there is always a significant delay between when a book chapter is written and when the printed version reaches us. As a result, a significant portion of our books, particularly in the field of treatment, is outdated. Evidence-based medicine provides tools to address these issues, showing how to find, evaluate, and apply valuable clinical information in a patient's unique context in the least amount of time. This way, diagnostic and therapeutic interventions are generally implemented only when their effectiveness is well-established, and harmful or ineffective interventions are avoided. As a result, many countries, especially developed ones, have turned to evidence-based medical education and practice.

Along with this acceptance, evidence-based medicine has also faced some negative reactions. Over the years, a range of criticisms has been directed at it, from claims that evidence-based medicine is just an old hat to accusations that it is a dangerous innovation aimed at cutting costs and suppressing clinical freedom. The pioneers of this movement, when describing what evidence-based medicine is and isn’t, assert that evidence-based medicine is neither an old hat nor an impossible practice nor a tool for suppressing clinical freedom. The argument that "evidence-based medicine is something everyone is already doing" is based on evidence before studies demonstrated the significant diversity in how doctors integrate patient values into their practice and the extent to which they provide various interventions to patients. Additionally, physicians face challenges in keeping up with all the medical advancements reported in major journals. These challenges are highlighted by comparing the time required to read the necessary material (for general medicine, reviewing 19 articles per day, 365 days a year) with the time available (at best, less than an hour a week for British physicians, even according to their own reports).

The argument that evidence-based medicine can only be practiced in an ivory tower, behind a desk, and in an imaginary way is refuted by audits of frontline clinical care, where at least some clinical teams responsible for hospitalized patients in general medicine, psychiatry, and surgery have managed to provide evidence-based care for the vast majority of their patients. These studies show that busy doctors, who dedicate their limited time to selective, efficient, patient-centered searches, evaluations, and integration of the best available evidence, can practice evidence-based medicine.

They also argue that evidence-based medicine is not about following a "cookbook" approach. Since evidence-based medicine requires a bottom-up approach that integrates the best external evidence with individual clinical experience and patient choices, it cannot lead to an approach that simply mimics others and follows a cookbook in caring for a unique patient. External clinical evidence can inform the physician, but it can never replace individual clinical experience. It is this experience that determines whether the external evidence is applicable to the patient and, if so, how it should be integrated into clinical decision-making. Similarly, any external guideline must be integrated with individual clinical experience to decide whether and how it aligns with the patient's clinical situation, dilemmas, and preferences, and whether it should be implemented. In fact, physicians who fear cookbook-like top-down approaches are supporters and allies of evidence-based medicine.

Despite its ancient roots, evidence-based medicine is a relatively young field of knowledge whose positive effects are just beginning, and it will continue to evolve. As evidence-based medicine increasingly enters educational programs at various levels of general medical education, specialization, and continuing education, adapting to the needs of its learners, this evolution will increase.

Ultimately, evidence-based medicine is the logic and common language of modern medicine today; a scientific and shared language that has influenced clinical decision-making and clinical research over recent decades.

 

 

Dr. Akbar Soltani