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Seven Alternatives to Evidence-Based Medicine

Correspondence: David Isaacs, M.D., Departments of Education and Medicine, New Children's Hospital, Westmead, NSW 2145, Australia. e-mail: davidi{at}nch.edu.au

Clinical decisions should, as far as possible, be evidence based. So runs the current clinical dogma [1, 2]. We are urged to lump all the relevant randomized controlled trials into one giant meta-analysis and come out with a combined odds ratio for all decisions. Physicians, surgeons, nurses are doing it [3-5]; soon even the lawyers will be using evidence-based practice [6]. But what if there is no evidence on which to base a clinical decision?

PARTICIPANTS, METHODS, AND RESULTS

We, two humble clinicians ever ready for advice and guidance, asked our colleagues what they would do if faced with a clinical problem for which there are no randomized controlled trials and no good evidence. We found ourselves faced with several personality-based opinions, as would be expected in a teaching hospital. The personalities transcend the disciplines, with the exception of surgery, in which discipline transcends personality. We categorized their replies, on the basis of no evidence whatsoever, as follows:

Eminence-Based Medicine
The more senior the colleague, the less importance he or she placed on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence. These colleagues have a touching faith in clinical experience, which has been defined as "making the same mistakes with increasing confidence over an impressive number of years" [7]. The eminent physician's white hair and balding pate are called the "halo" effect.

Vehemence-Based Medicine
The substitution of volume for evidence is an effective technique for brow beating your more timorous colleagues and for convincing relatives of your ability.

Eloquence-Based Medicine
The year round suntan, carnation in the buttonhole, silk tie, Armani suit, and tongue should all be equally smooth. Sartorial elegance and verbal eloquence are powerful substitutes for evidence.

Providence-Based Medicine
If the caring practitioner has no idea of what to do next, the decision may be best left in the hands of the Almighty. Too many clinicians, unfortunately, are unable to resist giving God a hand with the decision making.

Diffidence-Based Medicine
Some doctors see a problem and look for an answer. Others merely see a problem. The diffident doctor may do nothing from a sense of despair. This, of course, may be better than doing something merely because it hurts the doctor's pride to do nothing.

Nervousness-Based Medicine
Fear of litigation is a powerful stimulus to overinvestigation and overtreatment. In an atmosphere of litigation phobia, the only bad test is the test you didn't think of ordering.

Confidence-Based Medicine
This is restricted to surgeons (Table 1).

There are plenty of alternatives for the practicing physician in the absence of evidence. This is what makes medicine an art as well as a science.

CONTRIBUTORS

DI and DF each contributed half the jokes and will both act as guarantors. Funding: None. Competing interests: None declared.

FOOTNOTES

Reprinted with permission from BMJ 1999;319:18-25. www.bmj.com

References

1. Evidence Based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. JAMA 1992;268:2420–2425.[Free Full Text]
2. Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem solving. BMJ 1995;310:1122–1126.[Free Full Text]
3. Sackett DL, Rosenberg WM, Gray JAM et al. Evidence based medicine: what it is and what it isn't. BMJ 1996;312:71–72.[Free Full Text]
4. Solomon MJ, McLeod RS. Surgery and the randomised controlled trial: past, present and future. Med J Aust 1998;169:380–383.[Medline]
5. McClarey M. Implementing clinical effectiveness. Nurs Manage 1998;5:16–19.
6. EBM and the IMF. J Exponential Salaries 1999;99:1–9.
7. O'Donnell M. A Sceptic's Medical Dictionary. London: BMJ Books, 1997.

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