SGEM#10: Ten Commandments of Evidence-Based Medicine

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Date: 4 November 2012

Something a little different this time. Always trying out new things on TheSGEM to improve knowledge translation and dissemination. Today I want to look at evidence-based medicine again. There are some critics of EBM. I appreciate the system is not perfect. There are a number of limitations to EBM.

Sir Winston Churchill said “democracy is the worst form of government except all the others that have been tried.” This is how I feel about EBM. It is the worst form of medicine except for all the other that have been tried.

Dr. Andrew Worster

Or I could quote JFK speech at the Berlin Wall ” Freedom has many difficulties, and democracy is not perfect”. EBM has many difficulties,and is not perfect. It can be hard coming up with a focus question and then using the appropriate methods. Interpreting the results can also be a challenge. But don’t panic, the EBM answer as my mentor, Dr. Andrew Worster, taught me is always…it all depends.

Do we really want to go back to non-randomized, non-blinded trials? We would still be using magnets to mesmerize patients and blood letting to treat sepsis.

This leads me to today’s podcast on the Ten Commandments of EBM. I have said in previous podcasts that most things in medicine are made of of five things. Look a the Ottawa Ankle and Knee Rules (guidelines) – five things. If there are only four we tend to make up a fifth and if there are six we combine two to make a total of five. It sort of reminds me of Mel Brooks in the movie History of the World Part I when he acts as Moses with the 15, 15…oops, Ten Commandments.

So here are the Ten Commandments of EBM according to me…

The Ten Commandments of Evidence-Based Medicine:

Adapted from Dr. John S. Yudkin, Emeritus Professor of Medicine, University College London and published in blog by Dr. Richard Lehman

Thou shalt endeavour to provide patient care based on the BEST evidence. (BEEM)
Thou shalt consider benefits of drugs as proven only by hard endpoint studies and not bow down to surrogate endpoints, composite endpoints or secondary endpoints for these are but graven images.
Thou shalt not worship Guidelines, for these are but the creations of Committees which even their own members do not strongly believe in the recommendations.
Thou shalt apply a pinch of salt to Relative Risk Reductions, regardless of P values, for the population of their provenance may bear little relationship to thy daily clientele.
Thou shalt honour the Numbers Needed to Treat (NNT), for therein rest the clues to patient-relevant information and to treatment costs.
Thou shalt also honour the Number Needed to Harm (NNH) such that primum non nocere (first do no harm).
Honour the elderly patient, for although this is where the greatest level of risk reside, so do the greatest hazards to many treatments.
Thou shalt not see drug reps, nor covet an Educational Symposium in a luxury setting like Hawaii.
Thou shalt share decisions on treatment options with the patient in the light of estimates of the individual’s likely risks and benefits.
Thou shalt be skeptical/critical of all that you are taught, even if taught by (KEENER KONTEST….?????).

Email your answer to the Keener Kontest to TheSGEM@gmail.com to win a fabulous skeptical prize.

Keener Kontest Winner: Last week’s winner was Dr. Dan Eickmeier, Seaforth, Ontario. He correctly answered that local anesthetic with epinephrine could be safely used in the tips of everything.

Do not forget to register for this years SkiBEEM conference in SilverStar Mountain Resort in British Columbia, Canada. It will be taking place on Feb 4-6, 2013. For more information please contact Teresa. We plan to do another PUBcast for TheSGEM at this years conference. So come for the CME, skiing/snowboarding and opportunity to be on TheSGEM podcast.

On a final note it is flu season. Keep yourself, your family and your patients healthy this year and get the flu shot. I put together a YouTube video last week for our hospital. It focuses on 10 common flu shot myths and is ment for a general audience. South Huron Hospital is the Little Hospital that Does…Flu Shots.

If you want to listen to a shorter podcast on why health care providers should all get the flu shot you can listen to Dr. Mark Crislip’s podcast#8: A Budget of Dumb Asses. Be warned that this is not for everyone and his podcasts come with a Black Box Warning:

“The following podcasts may include sarcastic comments, snide asides, and rants off the topic of infectious diseases and may cover political, societal, and popular culture concerns. I think it is part of the charm of the podcasts, but if you do not like smart ass, then these podcasts may not be your cup of tea and you should go elsewhere. But you can’t say you were not warned.”

Subscribe to TheSGEM on iTunes, follow us on Twitter, like us on FaceBook and be skeptical of everything you are taugh…even if (oops don’t want to give away the Keener Kontest answer).