Evidence-based medicine and the physician-patient dyad.

Introduction As the current debates throughout the US attest, there are wide disagreements about the shape of future US health care delivery. Nevertheless, a general consensus has emerged about the need for more efficient interventions that are based on reliable scientific evidence. This need has been filled by evidence-based medicine (EBM), which employs meta-analyses and randomized controlled trials (RCTs) to examine the effectiveness of interventions on large populations. These findings are reviewed by the Cochrane Collaboration, a group of volunteers from around the globe who publish their findings quarterly in the Cochrane Database of Systematic Reviews. Although it seems difficult to deny the efficacy of statistically robust research, medical practitioners, especially those involved in primary care, are often skeptical about EBM, fearing that the physician-patient encounter will be undermined, and with it, the most appropriate mechanism to determine a diagnosis and treatment. These physicians are sometimes portrayed as representing an older, more traditional segment of the profession, but their hesitancy also represents more than fear of change. Increasingly sensitive to this resistance, advocates continue to reassure practitioners that EBM will not subvert the physician-patient encounter but instead will integrate “the values and preferences of the informed patient.” Certainly before EBM becomes legislated by agencies and insurance companies alike, it deserves the same careful examination that it claims to have made of specific conditions. Although the RCT gold standard requires prospective studies, EBM is best evaluated through retrospective analysis—that is, in historical perspective. I argue that EBM must be closely evaluated and critically appraised because it is subject to its own set of defects. Such a revised EBM would be best implemented in a context that maintains sensitivity to individuality and to physician-patient interactions. Background The ascendency of EBM in North America and the United Kingdom has its roots in the exponential growth of medical scientific research in the post–World War II years. By the third quarter of the 20th century, medical research had become a scientific enterprise, whereas much of medical care remained an art. The goal of EBM was to transform the art of medical care into a science. However, as Kathryn Montgomery has recently argued so eloquently, despite its reliance on scientific knowledge and its use of technology, medicine is not a science. Rather, it is a science-using practice whose goals are to prevent illness and care for the sick. The issue remains of whether EBM enables physicians to more fully practice their craft or whether instead, as a number of authors whose works are discussed here indicate, EBM has created an additional barrier to doing so. EBM was envisioned as a division of labor in which scientific evidence would be generated by researchers at prestigious research and medical institutions and implementation would take place in practitioners’ clinics. In reality, many clinical trials are done in the private offices of specialist physicians who derive a significant amount of income from the pharmaceutical industry. Nevertheless, such a system, whether intended or not, has produced a growing schism between academic medicine and clinical practice that often finds expression in concerns over the impact of EBM on the integrity of the physician-patient relationship. This tension has its roots in the 1970s, when academic medicine, emphasizing its connection to research, began to distinguish itself from normal clinical practice. By the 1980s, it became clear that medical research was not easily translated into practice. Thus, researchbased medicine was augmented by the establishment of professional clinical practice guidelines based on evidence gleaned from retrospective reviews of published RCTs. Practitioners, however, did not apply the