Medicine based on evidence is not EBM the meaning of evidence

In the chapter that introduced the first edition of this book,3 I distinguished between medicine based on evidence and Evidence-Based Medicine. The capital letters were intentional, and allow the abbreviation EBM. EBM relies mainly on randomised controlled trials (assessed explicitly and strictly), meta-analyses, and megatrials. Although we know that proper evidence is lacking in many fields of health care, nobody argues against medicine that is based on evidence. But EBM is a conceit: it appropriates the word "evidence" placing its own specific meaning on it, and thereby puts critics of EBM - who are presumed to object to the use of evidence at all - at a disadvantage. It is in the meaning of evidence that the disagreements and criticisms lie, and they have not yet been resolved: the evidence of EBM is based in clinical epidemiology, which, as Charlton (see above) drew out4,5 from the ideas of Feinstein6,7 among others,8 is not a sound foundation for the treatment of individual patients.

My own syntheses of these ideas, in detail and fully referenced, are in Chapter 1 of the first edition,3 and also in a subsequent essay.9 The arguments from that essay were then developed further,10 and they still stand. What little counter-criticism there was11 suffered the problem common to many attempted refutations: getting trapped in the rhetorical bind of using the word "evidence" in the general sense, and not in the specific sense of EBM.

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