Intended for healthcare professionals

Editor's Choice

Evidence based medicine: flawed system but still the best we’ve got

BMJ 2014; 348 doi: (Published 22 January 2014) Cite this as: BMJ 2014;348:g440

Evidence based medicine (EBM) not evidence-based: medicine is broken.

Dear Editor,

I want to formally reject the null hypothesis of my research.(1)

I respectfully disagree with the statement about EBM in the title of this article: "flawed system but still the best we've got."

I think is quite the opposite: it is probably the worst we've got.(2)

You mentioned Winston Churchill in this paper and I would like to quote him: "We shall not surrender."

The strength of evidence has been frequently represented as a pyramid: there is no pyramid of evidence - it is a collective delusion and now medicine has been severely broken.

We must fix medicine now, but first we must recognize that EBM is not evidence-based and it is causing medicine a great damage. We need to stop this nonsense now before it's too late.

It was already predicted by one of the most cited EBM (position 28th out of 9.476 articles) articles on ISI Web of Knowledge (2001 - 2014).

"If treatment decisions are made on the basis of misleading methodological tests, the costs to patients and society could be high." (3)

The most cited articles regarding EBM are:

1st. Surviving sepsis guidelines: 2008 (2303 citations)
2nd. Surviving sepsis guidelines: 2004 (1571 citations)
3rd. to 50th. Available on reference number 4.

This is also evidence that citations do not reflect the quality of an article, as well as the impact factor does not accurately measure the reputation of a peer-review journal.

I will submit my research findings hoping to receive a strict prepublication and postpublication peer review according to the best available evidence.(5)

Yours sincerely,

Jorge Ramírez


1. Hierarchical levels of evidence based medicine (EBM) are wrong.

2. Is the pharmaceutical industry like the mafia? Yes.

3. Lau J, Ioannidis JPA, Terrin N, et al. The case of the misleading funnel plot. BMJ 2006;333:597–600. doi:10.1136/bmj.333.7568.597

4. Chaos theory to evidence-based medicine: Hello!
URL: (date accessed: Dec 17, 2014).

5. Evidence based publishing. URL: (date accessed: Dec 17, 2014).

Competing interests: Non-financial conflict of interests:

17 December 2014
Jorge Hernán Ramirez
Professor of Pharmacology
Universidad del Valle
Cl 4B No. 36-00