Rebuttal of Pro

of EBM would argue that high quality evidence obtained through clinical epidemiologic methods should be ignored in the context of patient care. Nor would anyone argue that the current best evidence should be conscientiously, explicitly, and judiciously utilized when caring for an individual patient. REFERENCES 1. Evidence-Based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine. Popular, scientific, and medical culture in the United States favor the rhetoric of a dichotomous " all or nothing " response to a subject. Proponents of Evidence-Based Medicine (EBM) have taken this approach and have pushed for the abandonment of " authority-based " medicine in favor of EBM. Unfortunately, rhetoric rarely reflects reality and nowhere is this truer than in clinical practice in the Emergency Department (ED). While Dr. Fee and I agree in theory that EBM should be incorporated more into clinical practice, we disagree about the current overall effectiveness of EBM within the ED. The scope and depth of research underlying EBM is unable to generate " pure " evidence-based clinical guidelines on even the most well studied clinical questions. Most of us would agree with Dr. Fee when he quotes the Evidence-Based Medicine Working Group, " all medical action of diagnosis, prognosis, and therapy should rely on solid quantitative evidence based on the best of clinical epidemiological research. " Certainly, clinical guidelines, which grade the level of evidence supporting recommendations, allow the integration of the results of multiple randomized studies. It is important, however, to realize two things about these guidelines. First, many of these clinical guidelines contain recommendations that are based on expert consensus opinion, not evidence, as in the class 1C (C stands for consensus) recommendation from the AHA on treating acute coronary syndromes with nitrates and morphine. 1,2 While I agree with Dr. Fee's statement, " there are simply too many questions and too many variables to control to realistically expect a RCT to be available to answer every clinically relevant issue, " let's not call this " pure " EBM. Secondly, the majority of clinical decisions made in the ED don't even approach this level of evidence. At best, most of our decisions would only be supported by 3D recommendations (Dr. Fee's table) or AHA class 2A/B evidence. EBM, as it currently stands, is unable to consistently and appropriately evaluate and integrate evidence from studies other than randomized clinical trials; however, these …