I always was a fierce defendant of evidence-based medicine. After all, what harm is there in finding, using and being able to reject the available evidence for a particular question. Although we never learned it in medical school, I did some postgrad courses on medical literature appraisal, ploughed through the User’s Guide and tried to understand the mechanics of metaanalysis. I also follow most of the relevant Neurology journals. Still, I am unable to answer any given bedside clinical question in the way EBM would have it. It just takes too long and I am too dumb. Properly reading a study takes hours and then I am not able to find all weaknesses that internet blogs find in it.
So either I am unsuited for EBM or it does not work. Also, it just explains how to answer questions, not how to raise them.
With these fears in the background, I stumbled upon this paper and this talk, explaining a basic approach to what I would call informed medicine. I would add to the information in the article some core principles of work with medical literature:
- Try to stay current with the big journals (because they matter), but beware of their pharma influence.
- Try to stay current with some more independent and small journals (such as in PMC and the British journals).
- Follow informed discussions on the web (such as CCML, emcrit, …) in places where you reliably found good doctors.
- Don’t be an early adopter, unless a study has very small NNTs and has been replicated.
- Mistrust studies with thousands of participants, unless their (so-called scientific) results have been replicated in clinical practice.
- If facing a patient with a problem, read up in good textbooks written by people you trust and who are too old to be influenced by every small whiff of medical wind.
- Then confront this with something like uptodate.
- Finally read some reviews.
As a final remark, I offer the following strategy for finding a treatment for your patient: do a search on RCT with limits to 1970-1990 on your subject – you will find many rightfully abandoned approaches, but also some gems to be recovered.