Evidence-Based Medicine: Its Roots and Its Fruits

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The Roots of EBM The practice of evidence-based medicine (EBM) in the United States dates back to at least the 1980s. Some would argue, however, that the concept of “burden of proof” has undergirded medical decision-making since the days of Hippocrates. The basic premise of the Hippocratic oath, “primum non nocere,” or “first, do no harm,” challenges practitioners to evaluate the benefit of a therapeutic decision for a patient prior to implementation. In the modern era, the basis for analytical medical research includes inference testing that begins with a null hypothesis — a statement declaring the lack of effectiveness of the treatment in question — that must be rejected with a high degree of certainty to support the implementation of the treatment.1 The widespread acceptance of randomized clinical trials as the gold standard research design for generating the best evidence regarding treatment decisions was championed in the early 1970s by Archie Cochrane, an epidemiologist from Great Britain.2 Today the Cochrane Collaboration is an international group of physicians and researchers that offers health care providers carefully researched systematic review articles covering thousands of clinical questions, enabling busy practitioners to make evidence-based decisions without spending the time needed to appraise the evidence individually.3 The term EBM was introduced to US health care providers in an article published in the Journal of the American Medical Association in 1992 by Gordon Guyatt of McMaster University in Ontario, Canada. In the article, Guyatt and colleagues from the Evidence-Based Medicine Working Group discussed the importance of a shift in medical practice from relying on personal expertise and experience to a more objective, data-driven approach to medical practice.4 In the two decades since then, EBM has come to be defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”5 EBM is now taught in medical schools, residency programs, and physician assistant (PA) programs around the country. Students and medical practitioners are learning to develop a clinical question based on a specific patient problem, search the medical literature for articles that address the issue, critically review the quality of the evidence in the articles, apply the findings to their specific patient as appropriate,6 and then evaluate the clinical results and the effectiveness of the process.2 While the introduction and application of EBM principles have substantially changed the practice of western medicine, wholesale adoption of evidencebased practice is not without its challenges. Despite increased access to just-in-time evidence available at the bedside, a lack of consistent and reliable evidence for all encounters, time and resource constraints, barriers to the practice of high-quality medicine, and the misperception that it is an “ivory-tower concept”7 challenge implementation. One opponent to Feature Editors’ Note: