|
 Letters to the EditorRe: Editorial—Evidence-Based PsychiatryDear Editor: I offer some comments on your editorial appearing in the December 2003 issue of the Bulletin (1). The term “evidence-based” has led to considerable discussion and discord in the medical profession over the past decade. This discord seems likely to continue unless positive steps are taken to clarify the term and prevent its being used restrictively to include only statistically validated methods such as randomized controlled trials. According to a 1996 editorial in the British Medical Journal, “The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. . . . Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient” (2). In their clinical work, individual physicians constantly have to integrate available external evidence and internal evidence arising from their clinical expertise. This is how “evidence-based medicine” should be defined—as the integration of internal and external evidence. To prevent any more of the discord mentioned above, I think that all of us in the medical profession should take the following steps: 1. Ensure that the recommended definition of evidence- based medicine is adopted, used and promulgated. 2. Ensure that this definition is accepted and supported in teaching and in continuing education. 3. Ensure that this definition is recognized by editors of medical journals, so that both internal and external evidence have appropriate mutually supportive exposure in the literature. Will you be able to do something on the lines of these three steps in our Bulletin? Reference1. Goldbloom DS. Evidence-based psychiatry [editorial]. CPA Bulletin 2003;35(6):3,5. 2. Sachett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS, Evidence-based medicine: what it is and what it isn’t. BMJ 1996; 312:71–2. Peter Roper, MD Reply: Editorial—Evidence-Based PsychiatryI thank Dr. Roper for his comments. Evidence is not limited to “statistically validated randomized methods, such as randomized controlled trials” in any conceptualization of evidence-based medicine. Rather, there is a hierarchy of values for evidence, ranging from individual case reports on upward. To avoid the risk of diluting the meaning of the word “evidence,” I believe it is better to describe what he terms “internal evidence” as “clinical experience.” Of course, clinical experience has also been wittily defined as “making the same mistakes with increasing confidence over an impressive number of years” (1). “I know because I know” cannot be equated with other types of evidence in psychiatric therapeutics. Practising evidence-based medicine, as I had hoped to convey in the editorial, is about the integration of evidence narrowly defined into the other determinants of clinical decision-making, including clinical experience and patient preference. Reference1. O’Donnell M. A sceptic’s medical dictionary. London: BMJ Publishing Group; 1997. p 27. David S. Goldbloom, MD, FRCPC |