Evidence-Based Medicine: A Short History of a Modern Medical Movement

Abstract

On a cold morning in October 1993, Gordon Guyatt, a young faculty member at McMaster Medical School in Hamilton, Ontario, found a brochure published by the American College of Physicians (ACP) in his mailbox bearing this title: In This Era of Evidence-Based Medicine! (personal communication). For Guyatt, who had coined the term nearly 3 years earlier in a short editorial for the ACP Journal Club, the copywriter's blunt assertion proved not to be an exaggeration [1]. Over a short period, evidence-based medicine, defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" [2], had evolved into an emblem for an entire generation, becoming synonymous with the practices of quantification and statistics that pervaded the medical milieu at the end of the twentieth century. Indeed, an era of evidence-based medicine (EBM) had been ushered in.

Evidence-based medicine: is it a bridge too far?

“…There were three factors at the beginning of the 20th century that predated the development of EBM, namely (1) the transformation of hospitals in the USA, from a shelter for the sick, to prestigious organizations, where medical care was based on scientific principles [ 29 ]; (2) the reform of medical education [ 30 ], and (3) the birth of clinical epidemiology [ 31 ]. The transformation of hospitals was accompanied by a process of standardization of healthcare provision through guidelines, which was also closely related to the efforts of the American Medical Association to establish its position as the reference accreditation body in medicine [ 29 ].…”

“…The subject of clinical epidemiology was progressively introduced into medical programs based on the Enlightenment idea that progress was achievable through objectivity and rationality, so medicine has to be a science, not an art [ 29 ]. In 1968, McMaster University (Canada) was the first to offer an integrative ‘problem-based learning’ curriculum, combining the studies of basic sciences, clinical epidemiology and clinical medicine resulting from clinical problems [ 31 , 33 ]. The ‘father’ of EBM, David Sackett, directed this department.…”

“…In 1981, Sackett et al [ 33 ] published a series of articles in the Canadian Medical Association Journal that explained the criteria for assessing the internal validity of study designs as RCTs providing the gold standard for treatment, cohort studies for diagnosis, and case–control studies for etiology or harm. However, as Zimmerman indicated [ 31 ], this simplification was one of the most important weaknesses of EBM. Indeed, the major resistance to EBM relates to the specification of the knowledge base of medicine as something rational/technical/linear/predictable rather than contingent/experiential/non-linear/unpredictable [ 16 , 26 , 36 ].…”

“…However, as Zimmerman suggested [ 31 ], the EBM Working Group used a language closer to a political manifesto, calling for far-reaching changes in the practice of medicine, in the process creating an ‘enterprise of scientific objectivity’. This working group, together with Drummond Rennie, deputy editor at JAMA , remained the main advocates of the EBM movement for the first critical years: out of 22 articles on EBM published in the first 3 years, 12 were published by JAMA , reflecting Rennie’s and JAMA’s remarkable commitment to the new approach [ 31 , 46 ]. This new movement was not only sustained by JAMA , it also found the British Medical Journal to be its keen European supporter [ 1 , 47 ].…”

“…David Sackett and Iain Chalmers were renowned clinical epidemiologists and worked in highly regarded institutions – McMaster and Oxford University, respectively. Gordon Guyatt, as co-founder of the Medical Reform Group, a Canadian medical group composed of young doctors and nurses based in Toronto [ 31 ], notably agitated against the practice of medicine guided by senior doctors’ opinions. Personal experience gained under extreme conditions shaped the views of Archie Cochrane, a doctor and prisoner of war, and Iain Chalmers, a doctor in Gaza; they realized that in many cases new expensive treatments were no better than older ones [ 50 ].…”