Evidence based medicine: does it make a difference?

Editor—In the theme issue on whether evidence based medicine makes a difference Gabbay and le May ask whether guidelines are evidence based or “mindlines” that have been constructed collectively.¹ It is clearly time to change “evidence based medicine” to “evidence informed practice.”² Although “EBMers” have emphasised the importance of patients' values in decision making, this is missed in most discussions.

So that evidence is not displaced by mutant memes on the excuse that evidence ignores values and context (it doesn't), I suggest the era of evidence informed rather than evidence based medicine has arrived. I imagine patients would be either puzzled or concerned by this article and the subsequent discussion.³

When I am a patient I would like the (shared) decision making in the consultation to be informed by current best evidence for my condition. That doesn't mean a slavish obedience to results from randomised controlled trials. It means that good evidence forms part of the discussions. I would like to know what good evidence I might be potentially ignoring so that I can reach an informed decision: as either patient or doctor. The “mindlines” described accord with what I see—and may be helpful if they enrich the context of evidence (problems to watch out for or tips for doing the intervention). But the mindlines and memes are worrying if they supply counterfeit evidence: bad money drives out good money. Some recent mindlines and memes include hormone replacement therapy, bed rest for almost anything, and extraction of asymptomatic wisdom teeth.

So a puzzle remains: how do we get valid memes into the mindlines while not driving out the wisdom of experience? I suggest we start with evidence informed medicine and add a little wisdom.