BMJ 1996;312:71-72 (13 January)

Editorials

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

It's about integrating individual clinical expertise and the best external evidence
Evidence based medicine, whose philosophical origins extend back to mid-19th century Paris and earlier,
remains a hot topic for clinicians, public health practitioners, purchasers, planners, and the public. There are
now frequent workshops in how to practice and teach it (one sponsored by the BMJ will be held in London
on 24 April); undergraduate1 and postgraduate2 training programmes are incorporating it3 (or pondering how
to do so); British centres for evidence based practice have been established or planned in adult medicine,
child health, surgery, pathology, pharmacotherapy, nursing, general practice, and dentistry; the Cochrane
Collaboration and Britain's Centre for Review and Dissemination in York are providing systematic reviews of
the effects of health care; new evidence based practice journals are being launched; and it has become a
common topic in the lay media. But enthusiasm has been mixed with some negative reaction.4 5 6 Criticism
has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by
the arrogant to serve cost cutters and suppress clinical freedom. As evidence based medicine continues to
evolve and adapt, now is a useful time to refine the discussion of what it is and what it is not.
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making
decisions about the care of individual patients. The practice of evidence based medicine means integrating
individual clinical expertise with the best available external clinical evidence from systematic research. By
individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through
clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in
more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of
individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By
best available external clinical evidence we mean clinically relevant research, often from the basic sciences
of medicine, but especially from patient centred clinical research into the accuracy and precision of
diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and
safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates
previously accepted diagnostic tests and treatments and replaces them with new ones that are more
powerful, more accurate, more efficacious, and safer.
Good doctors use both individual clinical expertise and the best available external evidence, and neither
alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even
excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current
best evidence, practice risks becoming rapidly out of date, to the detriment of patients.
This description of what evidence based medicine is helps clarify what evidence based medicine is not.
Evidence based medicine is neither old hat nor impossible to practice. The argument that "everyone already
is doing it" falls before evidence of striking variations in both the integration of patient values into our clinical
behaviour7 and in the rates with which clinicians provide interventions to their patients.8 The difficulties that
clinicians face in keeping abreast of all the medical advances reported in primary journals are obvious from
a comparison of the time required for reading (for general medicine, enough to examine 19 articles per day,
365 days per year9) with the time available (well under an hour a week by British medical consultants, even
on self reports10).
The argument that evidence based medicine can be conducted only from ivory towers and armchairs is
refuted by audits from the front lines of clinical care where at least some inpatient clinical teams in general
medicine,11 psychiatry (J R Geddes et al, Royal College of Psychiatrists winter meeting, January 1996), and
surgery (P McCulloch, personal communication) have provided evidence based care to the vast majority of
their patients. Such studies show that busy clinicians who devote their scarce reading time to selective,
efficient, patient driven searching, appraisal, and incorporation of the best available evidence can practice
evidence based medicine.
Evidence based medicine is not "cookbook" medicine. Because it requires a bottom up approach that
integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in
slavish, cookbook approaches to individual patient care. External clinical evidence can inform, but can never
replace, individual clinical expertise, and it is this expertise that decides whether the external evidence
applies to the individual patient at all and, if so, how it should be integrated into a clinical decision. Similarly,
any external guideline must be integrated with individual clinical expertise in deciding whether and how it
matches the patient's clinical state, predicament, and preferences, and thus whether it should be applied.
Clinicians who fear top down cookbooks will find the advocates of evidence based medicine joining them at
the barricades.
Some fear that evidence based medicine will be hijacked by purchasers and managers to cut the costs of
health care. This would not only be a misuse of evidence based medicine but suggests a fundamental
misunderstanding of its financial consequences. Doctors practising evidence based medicine will identify
and apply the most efficacious interventions to maximise the quality and quantity of life for individual
patients; this may raise rather than lower the cost of their care.
Evidence based medicine is not restricted to randomised trials and meta-analyses. It involves tracking down
the best external evidence with which to answer our clinical questions. To find out about the accuracy of a
diagnostic test, we need to find proper cross sectional studies of patients clinically suspected of harbouring
the relevant disorder, not a randomised trial. For a question about prognosis, we need proper follow up
studies of patients assembled at a uniform, early point in the clinical course of their disease. And sometimes
the evidence we need will come from the basic sciences such as genetics or immunology. It is when asking
questions about therapy that we should try to avoid the non-experimental approaches, since these routinely
lead to false positive conclusions about efficacy. Because the randomised trial, and especially the
systematic review of several randomised trials, is so much more likely to inform us and so much less likely to
mislead us, it has become the "gold standard" for judging whether a treatment does more good than harm.
However, some questions about therapy do not require randomised trials (successful interventions for
otherwise fatal conditions) or cannot wait for the trials to be conducted. And if no randomised trial has been
carried out for our patient's predicament, we must follow the trail to the next best external evidence and work
from there.
Despite its ancient origins, evidence based medicine remains a relatively young discipline whose positive
impacts are just beginning to be validated,12 13 and it will continue to evolve. This evolution will be enhanced
as several undergraduate, postgraduate, and continuing medical education programmes adopt and adapt it
to their learners' needs. These programmes, and their evaluation, will provide further information and
understanding about what evidence based medicine is and is not.
Professor NHS Research and Development Centre for Evidence Based Medicine, Oxford Radcliffe NHS
Trust, Oxford OX3 9DU
Clinical tutor in medicine Nuffield Department of Clinical Medicine, University of Oxford, Oxford
Director of research and development Anglia and Oxford Regional Health Authority, Milton Keynes
Professor of medicine and clinical epidemiology McMaster University, Hamilton, Ontario Canada
Clinical associate professor of medicine University of Rochester School of Medicine and Dentistry,
Rochester, New York, USA
David L Sackett, William M C Rosenberg, J A Muir Gray, R Brian Haynes, W Scott Richardson

1. British Medical Association. Report of the working party on medical education. London: BMA,
1995.

2. Standing Committee on Postgraduate Medical and Dental Education. Creating a better learning
environment in hospitals. 1. Teaching hospital doctors and dentists to teach. London: SCOPME,
1994.

3. General Medical Council. Education committee report. London: GMC, 1994.

4. Grahame-Smith D. Evidence based medicine: Socratic dissent. BMJ 1995;310:1126-7.

[Free Full Text]

5. Evidence based medicine; in its place [editorial]. Lancet 1995;346:785. [Medline]

6. Correspondence. Evidence based medicine. Lancet 1995;346:1171-2.

7. Weatherall DJ: The inhumanity of medicine. BMJ 1994;309;1671-2.

8. House of Commons Health Committee. Priority setting in the NHS: purchasing. First report
sessions 1994-95. London: HMSO, 1995. (HC 134-1.)

9. Davidoff F, Haynes B, Sackett D, Smith R. Evidence based medicine: a new journal to help doctors
identify the information they need. BMJ 1995;310:1085-6. [Free Full Text]

10. Sackett DL. Surveys of self-reported reading times of consultants in Oxford, Birmingham, Milton-
Keynes, Bristol, Leicester, and Glasgow. In: Rosenberg WMC, Richardson WS, Haynes RB,
Sackett DL. Evidence-based medicine. London: Churchill Livingstone (in press).

11. Ellis J, Mulligan I, Rowe J, Sackett DL. Inpatient general medicine is evidence based. Lancet
1995;346:407-10. [Medline]
 12. Bennett RJ, Sackett DL, Haynes RB, Neufeld VR. A controlled trial of teaching critical appraisal of
the clinical literature to medical students. JAMA 1987;257:2451-4. [Abstract]

13. Shin JH, Flaynes RB, Johnston ME. Effect of problem-based, self-directed undergraduate
education on life-long learning. Can Med Assoc J 1993;148:969-76. [Abstract]

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