Evidence based medicine is a process that was developed, at least in part, to improve the quality of clinical research and enhance the users’ ability to understand, interpret, and critique studies prior to applying the findings into clinical practice.
As part of this endeavor, a hierarchy of research study design was developed with randomized controlled trials and, in particular, meta-analyses of randomized controlled trials at the top of the pyramid and expert opinion at the bottom. The evidence based medicine approach emphasized application of the best available research data with an understanding that the study design hierarchy is based upon the extent to which various study designs are susceptible to bias. In essence, the approach is a users’ manual for getting closer to the truth of research issues so that the information can be appropriately applied.
While the hierarchy of study design emphasizes certain methodologies over others, it is required that to qualify for the highest possible level of evidence, the respective study design must be planned, executed, and analyzed to its maximum effect. For example, a well designed and performed observational study may actually provide a higher level of evidence than a poorly executed randomized controlled trial. The reason for this relates, at least in part, to the extent of bias which may exist within the study.
Currently, the principles of evidence based medicine seem to not be as widely followed as desirable. Rather than using the best available data as the basis for opinions and recommendations, there is frequently an attempt to first devise a theory and then seek out data to support the already developed idea. This is the opposite of the scientific method in which hypotheses are tested through the accumulation of data and then updated an applied in future studies.
In addition, the current process does not follow the spirit, intent, or principles of the original description of evidence based medicine. As an example, in service of a preconceived theory, studies with higher levels of bias, particularly expert opinion, may be more heavily relied upon than studies of higher quality with less likelihood of bias which don’t support the preconceived notion. This undermines the scientific process and can lead to deleterious effects when applied, for instance in clinical practice and health policy.
To combat the current misapplication of evidence based medicine, a new paradigm is suggested. This is termed Evidence Driven practice. In this approach, the best available evidence is utilized to determine (or drive) opinions, recommendations, and theories. Wherever the evidence leads, the theories and conclusions follow, not the other way around. When data suggests that prior concepts or understandings were incorrect or incomplete, they are updated accordingly. This approach is agnostic of what is preconceived and believed to be true. Rather, Evidence Driven practice follows the best available evidence and seeks to derive theories on the basis of that data. This process allows us to progressively approach what is “true” rather than continuously seek out data that supports what we believe, or hope, to be “true”.
The Evidence Driven approach is at the foundation of The Practices of the Healthcare Athlete. Each of the practices and skills which are developed are on the basis of an evidence driven practice. This allows for advice and recommendations to be truly based upon the best available evidence irrespective of whether or not it corresponds to preconceived ideas.