Intended for healthcare professionals


Evidence based medicine: what it is and what it isn't

BMJ 1996; 312 doi: (Published 13 January 1996) Cite this as: BMJ 1996;312:71

Evidence-Based Medicine Revisited


The unprecendented capability of the open-access online publication
such as this in the British Medical Journal heralds a new interactive
forms of fora and publications not experienced before the introduction of
the Internet technology. The almost unlimited storage capacity of the
cyberspace in handling huge amount of data, textual and images make rooms
and spaces in the library rather redundant. Old articles published years
ago can be retrieved anytime anywhere as need arises. Issues that are
relevant now as they were before could be appraised and re-appraised
expeditiously without limits. Articles written years ago could be
retrieved and interactive feedbacks given anew based on fresh new ideas
and insights.

Evidence-Based Medicine (EBM) is one such issue. The apparent
moratorial paper published by the authors in 1996 seems relevant now as it
was in the past (1). The long list of associated papers and books on the
same homepage indicates the magnitude of importance given to the issue of
Evidence-Based Medicine by many researchers, writers and practitioners
alike. However, despite the enormous numbers of written books and articles
on EBM, much debates, misunderstanding and confusions still abound. The
degree of positive or negative passionate association with and pleas for
EBM varies between different authors. Much confusions and
misunderstandings arise from the extremely passionate argument to imbibe
EBM in clinical appraisal and practice.

The other major flaw in the exhortation of subscribing to EBM is the
overemphasis of Randomized Controlled Trials (RCT) as the panaceal
standard bearer of evidence within EBM argument. This line of debate seems
to overlook the dual components of EBM as vividly described by the authors
of this article, namely the internal evidence and the external evidence
(1). The explicit codified data of any RCT or even the meta-analyses of
the RCTs hailed as the Holy-Grail of therapeutic clinical evidence by the
extreme protagonists only addresses the external evidence within the whole
concept/philosophy of EBM.

The internal clinical evidence is depicted by the individual
clinician expertise and experience. This concept of clinician’s expertise
and experience contributing to the EBM is a very important conceptual
admission on the background of enormous amount of clinical information at
the clinician’s disposal to use. Furthermore, this idea would relate EBM
to the whole realm of clinical training and education. With the rapid
growth of scientific knowledge and the avid application of technology in
current clinical practice, advanced and ongoing clinical training and
education need serious attention to ensure that practicing clinicians are
fully equipped with the current internal clinical evidence.

It seems that the development of internal clinical evidence is a much
more intensive undertakings from the perspectives of both capital and
labour. This evidence is developed and based on the dynamism and
plasticity of human intellect. The tacit information and knowledge
acquired by clinicians through years of training and apprenticeship is
hence given due credence in the whole context EBM. The ultimate utility of
the codified external clinical evidence only depends on the appropriate
appraisal by the internal clinical evidence.

It is hoped that clinicians will not anymore be skewedly exhorted to
only use level I evidence from the scale of external evidence to base
their responsible clinical decisions (2). The title of this article is an
example of the wayward direction of the debates on EBM(2). The whole
discussion about evidence is for its appropriate utility in the practice
of Medicine rather than applied to the wider enterprise of exploration and
experimentation of science.

It is also hoped that expert technical surgeons will not be
inappropriately overtly ridiculed by the passionate proponents of external
evidence of EBM for their active exploration of the therapeutic horizon in
using new technology to effect state-of-the-art interventional therapy
especially on uncommon diseases(3).


1. David L Sackett, William M C Rosenberg, J A Muir Gray, R Brian
Haynes, and W Scott Richardson
Evidence based medicine: what it is and what it isn't
BMJ, Jan 1996; 312: 71 - 72.

2. J. Arya, H. Wolford, and A. H. Harken
Evidence-Based Science: A Worthwhile Mode of Surgical Inquiry
Arch Surg, November 1, 2002; 137(11): 1301 - 1303.

3. Horton R. Surgical research or comic opera: questions, but few
answers. Lancet 1996;347:984-5.

Competing interests:
None declared

Competing interests: No competing interests

26 January 2004
Abd H Mat Sain
Deputy Director
Advanced Medical and Dental Institute, Universiti Sains Malaysia, 11800 Penang, Malaysia