LETTER TO THE EDITOR
Year : 2014 | Volume
: 27 | Issue : 3 | Page : 302--303
Beyond evidence-based medicine : Need for a new paradigm in patient care delivery
Anuruddha M Abeygunasekera
Department of Urology, Colombo South Teaching Hospital, Dehiwela, Sri Lanka
Anuruddha M Abeygunasekera
Colombo South Teaching Hospital, Dehiwela
|How to cite this article:|
Abeygunasekera AM. Beyond evidence-based medicine : Need for a new paradigm in patient care delivery.Educ Health 2014;27:302-303
|How to cite this URL:|
Abeygunasekera AM. Beyond evidence-based medicine : Need for a new paradigm in patient care delivery. Educ Health [serial online] 2014 [cited 2020 Apr 6 ];27:302-303
Available from: http://www.educationforhealth.net/text.asp?2014/27/3/302/152200
Several decades ago, medical personnel used to practice Ego-based Medicine where the doctor's decisions were solely based on memory of his/her past experience. There was no collection of data and systematic and critical analysis of that data before decisions were arrived at. For many reasons (lapses in human memory, patients seeking treatment elsewhere after development of complications, etc.), errors made in decision-making were overlooked. With the popularity of robust research methodology and easier dissemination of research findings through medical journals, deficiencies of Ego-based Medicine became evident.
Those who realized the perils of Ego-based Medicine, found a new paradigm to improve patient care three decades ago. This was termed Evidence-based Medicine (EBM). Accordingly, medical personnel were requested to base their decisions in patient care solely on scientific evidence available and agreed upon by the medical community. EBM was an important and necessary step forward from Ego-based Medicine. Therefore, the medical world embraced EBM as the new paradigm. EBM was more scientifically appealing than Ego-based Medicine and helped tremendously to improve health care. The concept of EBM is so convincing that some consider it the holy grail of medicine.
However, after practicing EBM for several decades, we have encountered some deficiencies in the framework. EBM is defined as conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.  Yet, those who practice medicine in real life situations know that these idealistic words in the EBM definition are only a utopian dream in the real world. Such perfect health care is so expensive and demanding that it can be provided only to a handful of members of society, especially in resource poor settings in developing countries.
Medical personnel who try to provide reasonable health care to all members of society will be reprimanded for ignoring EBM in their practice. Overall, EBM has become a catch word that is abused by those who want to provide 'perfect' health care to a few privileged patients in society. It has also provided a 'scientific back-up' to those in the industry who want to sell their expensive products (with marginal or no benefits to the patient) for personal gains and to make exorbitant profits. 
Publication bias, language bias, support for research from the pharmaceutical industry and lack of research in local settings of the developing world are some of the obstacles faced in the search for current best evidence. Cultural differences, social differences and cost effectiveness make the issue even more complex. Cost effectiveness, which is crucial for the sustenance of any healthcare system, is greatly ignored in EBM as there is hardly any research on cost effectiveness of therapeutic interventions in the developing world. This has led to diversion of limited available resources in developing countries to relatively expensive interventions as medical personnel are forced to endorse such processes based on evidence generated in the developed world. Failure to do so may lead to allegations of malpractice and litigation. Future guidelines and protocols based on EBM are abused by parties interested in making money out of litigation. The result is EBM promoting defensive medicine.
The time is opportune for the medical community to find a new paradigm in the delivery of health care, which would rectify the deficiencies of the concept of EBM when practiced in resource poor countries and settings. It does not mean we should completely abandon the concept of EBM. Medical practice should be based on EBM but it should not be the final arbitrator. The main aim of the new paradigm would be to provide reasonable health care to all. This could be appropriately called Equity-based Medicine. At present, there is no political and administrative will or leadership to appreciate and support those who provide reasonable health care to all segments of the society in resource poor settings. Health policy makers and planners are also misguided and frightened by the concept of EBM and have no courage to contest the inappropriateness of EBM in resource poor settings.
We need more research on cost effectiveness done at the point of delivery. Guidelines should take into consideration the situation in the local setting. Politicians, administrators and decision makers should be encouraged to give leadership to low cost health care and reasonable care to all rather than ideal care to a few.  Changes should be made in the legal framework to accept Equity-based Medicine as the new paradigm. We changed from Ego-based Medicine to EBM two decades ago. Now it is time to improve EBM and move into Equity-based Medicine.
|1||Sackett 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.|
|2||Wilson CB. Adoption of new technology. BMJ 2006;332:112-4.|
|3||Abeygunasekera AM. Egalitarianism is the key to improvement. BMJ 2004;328:838-9.|