Intended for healthcare professionals

Rapid response to:


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

Rapid Response:

The rich and fertile tapestry of evidence

An evidence-based medicine that prizes meta-analyses and randomised-
controlled trials can help establish the most appropriate treatment for
large populations with the same clearly defined clinical condition.
However, such treatments will inevitably fail some patients whilst
inferior comparator groups will not completely lack success.

Individuals are not populations. Symptoms might not be singularly
ascribed to clearly-defined clinical conditions. Many aspects of the
doctor-patient relationship have powerful therapeutic impacts in their own
right. The treatment with the best evidence-base is useless for a
particular patient if it fails them and, in the management of acute
symptoms, must be replaced by plan B or beyond. Such ideas typically
confound contemporary EBM. Some medical disciplines require an EBM that
understands the uniqueness of each situation; accommodates a bit more
diagnostic uncertainty; exploits the importance of the doctor-patient
relationship; and suggests other options when the “best” choice fails.
This potentially legitimises academic conjecture and therapeutic
empiricism. It even keeps the door open to such things as case histories.
Whilst contemporary EBM is vitally important, so is much of the material
that it deliberately excludes. This might help explain the diversity of
publication types found in most thriving medical journals.

Competing interests:
None declared

Competing interests: No competing interests

22 October 2008
John C Chambers
Macmillan Consultant and Medical Director
Katharine House Hospice, East End, Adderbury, Oxon, OX17 3NL