儘管我總是說實證醫學是高級查字典比賽,但是並不是說EBM不好,EBM應該是每一個學醫學的人必備的技能。

只不過,在以文書作業盛行的中華民族的渲染下,愈來愈偏離他原先的經隨

基本上,臨床經驗還是最重要的,而文獻,就是在驗證臨床經驗的正確性。

這種感覺就好比大家都會有太陽繞著地球的經驗(東邊升起西邊落下),但是科學卻證明其實是地球繞著太陽公轉,而日出日落是地球自轉的關係。

字一定會比字典先出現,字典卻是字詞和語意的整理。

所以當這樣的邏輯被反轉時,就會出現偏移現實的誤差。

當然,奸商不是只有亞洲才有,大統、味全、遠通這類型企業也不是台灣的專利,在醫藥發達的國家裡面,也步伐某些廠商或是研究機構的刻意操作。

沉迷於文獻的咬文嚼字,對臨床醫學可能非但沒有益處,更貽害後人。

最近剛好也有人提出相似的考量,參考一下吧

Evidence based medicine is so much part of the air we breathe it can be hard to remember a time before it. An oral history, filmed for a joint JAMA and BMJ celebration last year, has now been published on bmj.com/evidence and the JAMA network. As summarised in an editorial co-published by the two journals this week, the story features a satisfying array of heroes and detractors, forward progress and backlash (doi:10.1136/bmj.g371).

Why did evidence based medicine take off? In the video, and quoted in the editorial, David Sackett provides two main reasons: it was supported by senior clinicians who were secure in their practice and happy to be challenged, and it empowered younger doctors—and subsequently nurses and other clinicians—to question received wisdom and practice.

Sackett and his generation also succeeded because they were natural iconoclasts. And now that evidence based medicine is part of the medical establishment and is itself an icon, it’s only right that it has become a target for the new iconoclasts. In a recent column Des Spence claimed that evidence based medicine was broken and that the research pond was polluted by fraud, sham diagnosis, short term data, poor regulation, surrogate endpoints, and clinically irrelevant outcomes (doi:10.1136/bmj.g22).

Spence said that evidence based medicine left no room for discretion and fuelled overdiagnosis and overtreatment. A good number of rapid responders agreed (http://bit.ly/1jkDFZ8), some even saying he didn’t go far enough. Others defended the precepts of evidence based medicine and warned against throwing the baby out with the bathwater.

This week we highlight a story that could be used to argue either way. Rita Redberg and colleagues describe the saga of the Wingspan intracranial stenting device (doi:10.1136/bmj.g93). They tell us that its continued licensing and use in people with a previous stroke were based on a single, industry funded, uncontrolled study of 44 patients, while the only randomised trial showed clear evidence of increased deaths and strokes when the device was compared with medical treatment.

The Wingspan has been licensed under a special regulatory programme for high risk devices in rare conditions. In an accompanying commentary, Hwang and colleagues highlight the generally poor quality of the evidence for such devices, mainly small and uncontrolled studies (doi:10.1136/bmj.g217). Both sets of authors call for far greater regulatory scrutiny of the safety and effectiveness of medical devices.

As with democracy and peer review (with apologies to Winston Churchill), evidence based medicine may be the worst system for clinical decision making, except for all those other systems that have been tried from time to time. It is only as good as the evidence and the people making the decisions.

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