Future research methods must find ways of accommodating clinical reality, not ignoring it

Seeking an evidence base for medicine is as old as medicine itself, but in the past decade the concept of evidence based medicine has done a good job in focusing explicit attention on the application of evidence from valid clinical research to clinical practice.1 2 Although current clinical practice is often evidence based,3 4 there is still much to be gained. Important new evidence from research often takes a long time to be implemented in daily care, while established practices persist even if they have been proved to be ineffective or harmful.5 In the meantime, many clinicians struggle to apply the results of studies that do not seem that relevant to their daily practice.

Evidence based medicine has been defined as the “conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”2 What can we learn from the limitations of current best evidence for the way that we design future studies?

We face the problem that criteria for internal and external validity (that is, clinical …