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From the Editor

3 types of ‘EBM’: Which do you practice?

Evidence, expert opinion, and personal experience are all vital components of a practitioner’s toolbox.

Vol. 6, No. 4 / April 2007

Psychiatric practitioners often are urged to practice evidence-based medicine (EBM), but some clinicians prefer to follow expert consensus guidelines—Eminence-Based Medicine. Still others uphold their own practice observations—Experience-Based Medicine. Which form of EBM do you practice?

Pros and cons of each. The most scientifically credible EBM is based on evidence from double-blind, randomized controlled clinical trials, such as those conducted by pharmaceutical companies seeking FDA approval of a new drug or indication. Critics point out, however, that this form of EBM does not reflect real-world practice because patients in FDA pivotal trials often are “too clean”—they’re frequently treatment-responsive and not drug-dependent, medically ill, or receiving other medications.

Eminence-based medicine—usually disseminated in practice guidelines—is respected because it reflects recommendations of some 30 to 50 experts on a set of psychiatric disorders (usually prominent clinical researchers with a critical approach to data). However, many practice guideline algorithms are based on educated opinions and extrapolations from narrow evidence-based data that are extended to various manifestations of a specific disorder.

Experience-based medicine, which combines evidence-based principles with a hefty dose of personal clinical observations in a heterogeneous patient population over time, is a prevalent source of information for clinical practitioners. Research purists often brush aside this form of EBM as too subjective, or because they feel using it can lead to risky conclusions about how to use a particular therapy. A common criticism of experience-based medicine is that a placebo response, which can occur in up to one-third of psychiatric patients (as can be seen in most FDA registration trials) may masquerade as a positive outcome.

A role for all three. In my opinion, research-driven, evidence-based medicine is the indispensable foundation for medical decision-making, but expert opinion and personal experience legitimately belong in a clinician’s toolbox as well. Treatments for psychiatric disorders have been evaluated in randomized controlled trials (first-tier evidence) for only a small proportion of DSM-IV diagnoses. What’s a clinician to do when faced with a disorder for which evidence-based medicine has proven no treatment to be effective? This is where the art of medicine comes into play.

Combining art and science. A clinician can try an intervention that may be supported by weaker evidence, such as from single-blind studies (second-tier evidence) or several published case series or reports. When nothing else has worked, such as in treatment-resistant patients or those with complex comorbidities, a clinician may boldly go where no one has gone before and try a novel but untested combination. Such a therapeutic foray is high-risk exploration that may fail dismally—or it may serendipitously usher in a radical yet effective new approach to alleviating the symptoms of a serious disease.

Clinicians who stumble upon a new approach should publish their observations in a letter to the editor or case report to stimulate replications, rebuttals, or additional personal observations. Subjecting unexpected findings to critique and refinement in the dynamic market of ideas can increase their value.

Eminence-based practice guidelines—through a reasonably calibrated amalgam of evidence and experience—provide clinicians with a series of steps and an acceptable risk–to-benefit ratio to manage patients who do not respond adequately to evidence-based treatment. Consensus-driven expert opinion integrates the art and science of medicine and commands greater credibility than the opinion of a single clinician.

Using every tool. Each of us implements all three types of EBM when managing our patients. We need to, and we have to. That is the reality of the medical practice of psychiatry.

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