Leading articles Evidence based medicine

Traditionally the physician's absolute right to decide what treatment any individual patient should be oVered has been the Holy Grail of clinical practice since the earliest of time. Such a decision has clearly always been influenced by individual physician experience, and the presented or published results of fellow practitioners. The first medical research trials to investigate the use of patulin treatment in the common cold 1943–44 (double blind controlled trial with quasi randomisation) 1 and of streptomycin in tuberculosis 1947–48 (randomised control trial but with no placebo) 2 heralded in a new era. Bradford Hill is reported to have been worried " that doctors would be unwilling to relinquish the doctrine of anecdotal experience " when he proposed the concept of randomised clinical trials. 3 4 The randomised clinical trial has become the " gold standard " by which the choice of treatment and evidence to support its use is now judged. The physician inevitably must ultimately decide, based on knowledge of the patient's overall health, both physical and emotional, as to whether such trial evidence should be applied to that particular individual. It has become fashionable and indeed commendable to demand the evidence base for all medical actions, using the data from any randomised clinical trial and systematic overviews. The British Medical Journal and the American College of Physicians indeed created a team who have worked together to produce an evidence formulary on the prevention and treatment of common ailments, including areas of uncertainty and doubt, 5 for example, in atopic eczema. 6 Almost inevitably there has been a backlash with challenges made to the reliability and applicability for the individual of evidence based on randomised controlled trials and overviews. 7 Goodman 8 argues that " the presumed opinionated dogma of the expert " may have been replaced by dogma from a diVerent source. Much of the criticism revolves around known trial publication bias (for positive results), the lumping of trials of various sizes and quality into meta-analyses (each with unknown inbuilt flaws), and then the extrapolation of results back to the individual patient. Those who carry out and believe in the value of meta-analyses have argued publicly about optimal methodology, giving support to their detractors. Indeed there appear to be two competing factions who are waging a fairly public war on the whole question of evidence based medicine. Those who believe that randomised clinical trials (preferably double blinded), …