Evidence-Based Medicine and its discontents (with Gordon Guyatt)
1. Practice Shared Decision-Making
Engage in shared decision-making with your doctor, understanding that you are the expert in your values and preferences, while the clinician is the expert in the evidence.
2. Understand Evidence Quality
Recognize that not all evidence is equal; randomized trials generally start as high-quality evidence, while non-randomized studies start as low-quality, but both can be downgraded or upgraded based on specific factors.
3. Prefer Randomized Trials
When possible, prioritize evidence from well-conducted randomized controlled trials over observational studies, as randomization helps avoid confounding bias where differences in people, not the intervention, cause observed effects.
4. Focus on Absolute Risk
When evaluating treatment benefits or harms, always consider the absolute risk reduction or increase, as relative risks can sound impressive but be trivial if the baseline risk is very low.
5. Beware Surrogate Outcomes
Be skeptical of treatments that only show improvement in surrogate markers (like HDL levels or blood glucose) without direct evidence of improving patient-important outcomes like mortality or major disease events.
6. Question Conflicted Sources
Be wary of medical information or recommendations from sources with conflicts of interest, particularly financial ties to the pharmaceutical industry or strong intellectual attachments to specific work.
7. Demand Honest Uncertainty
Expect authorities and clinicians to acknowledge uncertainty when it exists, as pretending to know when they don’t erodes trust and can lead to poor decisions.
8. Distrust Biological Arguments Alone
Do not rely solely on biological arguments or physiological reasoning for treatment efficacy, as history shows these can be misleading and even harmful; always seek evidence from randomized trials.
9. Assess Study Limitations
When evaluating studies, consider factors that can lower evidence quality, such as risk of bias, inconsistent results, small sample sizes, indirect applicability to your situation, and potential publication bias.
10. Prioritize Patient-Important Outcomes
When evaluating treatments, focus on those that demonstrably improve long-term patient-important outcomes (like cardiovascular and renal risk) rather than just surrogate markers.
11. Evaluate Screening Test Risk
If you are at low risk for a condition, be cautious about screening tests, as they can lead to false positives and unnecessary interventions, and may be oversold to low-risk populations.
12. Minimize Hospital Stays
Avoid going to the hospital if not sick, and if in the hospital and feeling better, get out as soon as medically advised, as there are inherent risks and complications.
13. Skepticism on Moderate Alcohol
Approach claims about the health effects of moderate alcohol consumption with skepticism, as the evidence is often low-quality observational data and may be overplayed.
14. Address Severe Obesity
Recognize that severe obesity is unequivocally a major health problem with clear negative health outcomes, while the health implications of modest obesity are less certain.
15. Recognize Placebo Power
Be aware that placebo effects are real and can be substantial, especially in conditions with chronic symptoms that don’t spontaneously improve, and can significantly influence perceived treatment efficacy.
16. Question Disease Definitions
Be aware that definitions of diseases, especially in mental health (e.g., DSM), involve value judgments and are not purely evidence-based, and can change over time.
17. Demand High-Quality Research
Advocate for resources to be concentrated on a smaller number of large, well-done, high-quality studies rather than numerous low-quality studies that often yield misleading or unhelpful results.
18. Seek Evidence-Based Resources
When seeking medical information, consult up-to-date, evidence-based electronic resources and guidelines from reputable organizations that adhere to EBM principles.