Evidence-based medicine is only a restrictive interpretation of clinical medicine

In an article in the current issue of P&P a group of Italian investigators analyzes data that derive from  the most popular approach in clinical medicine nowadays, evidence-based medicine.

In their analysis, the Authors highlight that the gap between clinical guidelines developed by evidence-based medicine (EBM) and the clinical setting has been widely recognized. Indeed, there is currently little evidence that EBM has actually improved patient care. This may be due to the fact that results of randomized clinical trials may show comparative efficacy of treatments for the average patient but not for those whose characteristics, such as severity of symptoms, comorbidity and other clinical features, depart from standard presentations.

Furthermore, EBM is focused on the potential benefits that therapy may entail as to baseline risk, but it is likely to neglect other two main dimension such as responsiveness and vulnerability to the adverse effects of treatment. The Authors suggest that the achievement of such a balance is hindered by the difficult integration of different sources of information.

On one hand, guidelines tend to place emphasis on systematic reviews and meta-analyses of RCT that are uniquely geared to highlighting benefits. On the other hand, the appraisal of adverse effects relies primarily on observational studies and data from clinical practice and may not emerge from RCT, unless these effects occur early in the course of treatment and are specifically investigated.

EBM has certainly made an important contribution to questioning unsubstantiated therapeutic claims. However, as stressed by the Authors, the time has come to become more aware of its considerable limitations, including overall reductionism, disregard of patient-physician relationships and patient preferences, and insufficient consideration of problems related to financial conflicts of interest. " Evidence-based medicine is only a restrictive, pharmaceutically driven interpretation of clinical medicine. Time has come to challenge it" declares Giovanni A. Fava, MD.