Evidence based medicine: does it make a difference?

Editor—Garner et al reported a framework for shifting the clinical community towards using systematic reviews and evidence based medicine in low and middle income countries.¹ Their proposed structure tries to help implementation of evidence based medicine in a “top down” direction and through targeting groups with specific roles (“health ministry policy makers, professional groups, and managers with responsibility for clinical and public health policy”).

They did not consider another major group of users. We think that the resistance of direct care providers (clinicians, nurses, dentists, etc) to changes in clinical routines must be considered. In many parts of the developing world the essential concepts of evidence based medicine have not yet been incorporated by a considerable proportion of clinicians, and opinion based medicine still dominates.

Moreover, although the framework by Garner et al seems powerful for changing the behaviour of clinicians with regard to some common and profound clinical errors, it cannot change the attitude of clinicians towards evidence based medicine and is not practical for numerous minor clinical errors (which clinicians themselves should overcome by using evidence based medicine). With the suggested approach, the rate of exploitation of much available evidence would not be changed, and most systematic reviews and other valuable evidences would be still unused.

We think that, beside the proposed framework (implementation top down), the use of evidence should be promoted by evolution of evidence based culture among all members of the clinical community (dissemination bottom up). The foundation stones for an evidence based medicine “culture” should be laid by undergraduate students and prospective clinicians. Moving towards these goals needs education frameworks for policy makers as well as clinicians.