Evidence-Based Medicine and the Physician-Patient Dyad

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.1,2 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.3,4 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.”5 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.