The term EBM (evidence based medicine), as we use it nowadays, was introduced in 1992 by the same group of people who, years before, founded the discipline called “Clinical epidemiology” (CE).¹ CE stemmed essentially from the idea of adapting and expanding epidemiological methods to medical and health care decision making; CE was in fact defined as “ the discipline dealing with the study of the occurrence of medical decisions in relation to their determinants”.¹

CE has been very successful in illustrating new ways of teaching medicine and training health professionals, and has positioned itself around the notion that “critical appraisal skills” are yet another set of essential abilities which—in addition to the interpersonal, diagnostic, and prognostic skills—a good doctor should master. An important by product of CE was documentation which showed that much of the available evidence on diagnosis, prognosis, and treatment of diseases was of poor methodological quality and quite often of dubious transferability to everyday clinical practice.

This led to a strong call for improving the scientific basis of clinical practice, which was seen as too often dominated by practices of unproven effectiveness. This was the background for the 1992 Journal of the American Medical Association article that first used the term “evidence based medicine”.²

In essence, proponents of EBM said that “all medical action of diagnosis, prognosis, and therapy should rely on solid quantitative evidence based on the best of clinical epidemiological research”.² Also they stated that “we should be cautious about actions that are only based on experience or extrapolation from basic science”.² Indeed, this is not a new concept, as recent research into the history of medicine has documented.³ Vandenbroucke recently discussed the well rooted historical precedents for the CE and EBM movements in the history of methodological research in medicine quoting, among others, Alexandre Louis who led an initiative called “médecine d’observation” in France in 1830.³ Finding, not surprisingly, strong resistance from his fellow physicians, Louis stated that “physicians should not rely on speculation and theory about causes of disease, nor on single experiences, but they should make large series of observations and derive numerical summaries from which real truth about the actual treatment of patients will emerge”.³ Parallels and differences between now and then are worth noting here. In the early 1800s proponents, of “médecine d’observation” were reacting against a kind of medicine that derived its theories from many things that we would consider “nonsense” by today’s scientific standards. Today EBM acts in the context of a very different environment, in which modern medical basic science has a solid experimental background. We now know that “médecine d’observation,” failed shortly after its appearance. A strong reaction from the medical profession together with the absence of contextual conditions account for this unfavourable outcome. Will EBM experience a different outcome as it exists in a more scientifically oriented medical world? In many ways a similarly strong negative reaction has emerged today against EBM. No doubt one of the reasons for such a negative reaction against EBM has been the fact that it was labelled as a “shift in medical paradigm”. Such a definition would imply that EBM means scientific medicine and that all medicine practised before it was unscientific. This is not only simplistic but, as any closer scrutiny will reveal, profoundly wrong. The difference that needs to be marked is not that before EBM people did not use the evidence. Rather, the real failure was the lack of a framework and a set of rules to use the evidence in a systematic and explicit fashion.

Seen in this way the current fight around EBM and its nature could be advanced by moving the discussion from principles to a more pragmatic perspective, where the attention is centred on a “better use of evidence in medicine”. This would have the distinct advantage of indicating that it is the way in which, and the rules according to which, we use and interpret evidence that need to be changed.

In contrast to the traditional wisdom of clinical practice, stressing the need for “a better use of evidence in medicine” would indicate that intuition and unsystematic clinical experience as well as a pathophysiological rationale are insufficient grounds for clinical decision making. On the contrary, the modern practice of medicine finds its way by reliance on formal rules aimed at interpreting the results of clinical research effectively; these rules must complement the medical training and common sense of clinicians, whose uncontrolled dominance is no longer ethically and scientifically acceptable.

Struggling for a better use of evidence in medicine also has other important advantages. It challenges the paternalistic and authoritarian nature of much medical practice and helps increase awareness that—even when based on scientific methods—there is a selective and structural imbalance in the nature of the evidence that is available, because that evidence is skewed and biased toward therapeutic v preventive interventions and toward simple pharmacological v complex behavioural/social care. Acquiring critical appraisal skills—one of the most important tenets of the EBM movement—is the necessary (though not sufficient) and best immunisation against ignoring that there is a structural imbalance in the research agenda; an imbalance that should be overcome in order to make fully available the sort of evidence that is needed to provide effective and comprehensive health care to all patients.