The evidence house

The evidence houseHow to build an inclusive base for complementary medicine see also p 125We all want good evidence available when making medical decisions.Evidence, however, comes in a variety of forms and purposes, and what may be good for one purpose may not be good for another.The term "evidencebased medicine" (EBM) has become almost a cliche in recent years, being used as a synonym for "good" or "scientific," both to support and refute the value of complementary medicine practices. 1But EBM takes a narrow view of what constitutes "good" evidence, and it excludes important qualitative and observational information about the use and benefits of complementary medicine.The key idea of EBM is a "hierarchy of evidence" (figure 1).In this hierarchy, information from systematic reviews of randomized controlled trials is the "best" evidence, followed by individual randomized controlled trials, then by nonrandomized trials, observational studies, and finally case-series. 2When the evidence of what type of medicine works and what type does not is synthesized, the type of emphasis is at the top of the pyramid, and the evidence that is considered inferior is at the lower levels.Clinical experiments that isolate a causal and additive link between a specific intervention and a specific clinical outcome are seen as the "gold standard" in this evidence model.As most clinicians know, the reasons that patients recover from illness are complex and synergistic, and many cannot simply be isolated in controlled environments.The best evidence under these circumstances may be observa-tional data from clinical practice that can estimate the likelihood of a patient's recovery in a realistic context. 3In addition, patient's illnesses are complex physical, psychological, and social experiences that cannot be reduced to single, objective measures. 4In some cases, the most valuable information for a clinical decision is a highly subjective judgment about life quality.This personal ex-Figure 1 The traditional hierarchy of evidence is narrow ....