Evidence-Based Medicine in Medical Practice

“The integration of best research evidence with clinical experience and patient values.” –David Sackett. DEFINITION Evidence-based medicine (EBM) is the assiduous, unambiguous, well-judged, and practical use of modern, ethical value-based clinical research best evidence to make conclusions in delivering cost-effective and better health care to individual patients. EBM gives a clinician a new way of understanding and integrating the best clinical research, clinical expertise, and patient preferences to optimize clinical decision-making. Systematic reviews and meta-analyses are important milestones in applying EBM for better medical practice. What is true today in science may not be true tomorrow. The exponential growth of basic research and changing trends in patient value-added treatment patterns have put the clinician in academic isolation and to keep abreast of the knowledge needed to meet this scientific explosion and information overload of published literature.[1] EBM approach suggests reading and focusing only on specific clinical/patient problems to improve the clinician’s knowledge. It enhances the use of available relevant literature in reducing the gap between good clinical research and clinical practice. It identifies and promotes those practice preferences that improve quality care and also eliminates harmful and ineffective treatment modalities. EBM is a lifelong learning and application of the best clinical research evidence arrived through systematic reviews of medical literature to the individual patient on a specific clinical scenario by the medical practitioners.[2] In a limited time, clinicians can be highly selective and focus on knowing the latest trends in the various advancements in optimizing clinical care. WHAT IS THE EVIDENCE IN EVIDENCE-BASED MEDICINE? It is the most relevant and effective intervention or treatment in patient care based on the findings from patient-centered clinical research. A hierarchical system of classifying levels of evidence depending on the probability of bias is the cornerstone of EBM. The grading system has placed randomized controlled trials (RCTs) at the highest level because they are designed to have low selection bias and fewer systematic errors. As opposed, case series and expert opinions are graded as lowest.[3] However, higher the quality of evidence closer to the truth, though not a study design, taking the totality of the evidence, systematic reviews summarize the best available evidence in all types of study designs including cohort studies, case–control studies, and even case reports and hence in the hierarchy of evidence, systematic reviews are kept on the top. To overcome the shortcomings of the hierarchical pyramidal grading system, the “GRADE = Grading of Recommendations Assessment, Development, and Evaluation, system[4]” has been introduced, which resulted in great improvement in the quality of systematic reviews. For developing clinical practice guidelines and designing new research studies, systematic reviews are essential in standardization of the health care. EBM gives trustworthy clinical practice guidelines to the clinician, at the point-of-care delivery. These guidelines decrease inappropriate and wasteful procedures in clinical care and research.[5] Clinical expertise, so-called the art of medicine – medical education, clinical skills, and clinical experience, should be considered a complementary source of knowledge which supports the effective use of available literature and facilitates the collective clinical decision of patient care.[6] However, it is essential in framing the clinical question, collecting the evidence, appraising, integrating, and considering its ethical applicability to the patient. Choosing evidence from a peer-reviewed article mitigates the chances of misjudgment.[6] For individual patients with rare diseases, personalized research protocols are designed to improve care, by integrating, the best clinical research, and medical care and incorporating individual patients’ preferences. This led to individual point-of-care trials designed in lines of N-of-1 studies.[7] It is useful in determining optimal therapy, in patients with rare diseases, with comorbidities who do not meet the RCT criteria, or patients with unusual side effects or idiosyncratic treatment responses.[8] EVIDENCE-BASED MEDICINE STEPS IN CLINICAL PRACTICE Ask, acquire, appraise, apply, and assess are the important steps of EBM.[9,10] Asking well-built specific problem-oriented relevant answerable questions about the clinical case is the key to acquiring the best clinical research evidence from the medical literature databases (PubMed, Google Scholar, Trip Medical Database, etc.,). PICO (patient, intervention, comparison, and outcome)[9] model as a search strategy tool for creating the apt research question with which literature search improves the quality and comprehensiveness of the results and decreases errors. The clinician should possess the skills in exploring databases such as PubMed, Google Scholar, Embase, and Cochrane Library. He should be conversant with the use of keywords, Mesh terms,[11] Boolean operators,[12] and validation filters in acquiring appropriate evidence from the databases. Critical appraisal assesses the trustworthiness of the article and its relevance to the research question in a given situation. It evaluates the appropriateness of inclusion criteria, searching strategy, supporting data, and level of publication bias. JBI critical appraisal tools are the ones that are developed to aid in this process.[13,14] ADVANTAGES OF EVIDENCE-BASED MEDICINE IN THE MEDICAL PRACTICE By adopting EBM, one can minimize errors, reduce cost of treatment, and optimize the quality of patient care. It ensures the physician to daily access to the relevant literature advances in medicine and keeps him abreast with the present scientific progress. Thus, EBM indirectly influences the professional conduct of the physician more efficiently. This process maximizes the benefits of scientific research for patient care. There is a paradigm shift from expertise-based medicine to EBM. Let us strengthen the EBM movement through JOCR. HISTORICAL PERSPECTIVE David Sackett is considered to be the father of EBM. The word EBM was coined by Gordon H Guyatt in 1991.[15] Professor Archibald Cochrane (1909–1988) a British clinical epidemiologist insisted on systematic, up-to-date reviews of all relevant RCTs of health care, which has led to the founding of Cochrane Collaboration (1993)-http://www.cochrane.org. He could convince the medical world that EBM is a good tool for evaluating the research evidence for better medical care.[16]