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Posted by plosmedicine on 30 Mar 2009 at 23:43 GMT

Author: BM HEGDE
Position: Vice Chancellor Retired
Institution: Mangalore, India
Additional Authors: nil
Submitted Date: June 05, 2005
Published Date: June 5, 2005
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Dear Editor,

Facts do not cease to exist because they are ignored.
Aldous Huxley.

EBM should be a concerted effort to retrieve and synthesize as much data as is available to make it possible for practising physicians to incorporate in their practice. The conventional clinical acumen, intuition and clinical experience are deprecated in this process. I wonder if we have enough data to guide us all the time in clinical practice for the benefit of patients. One glaring example is the area of hypertension treatment. Whereas there are more than six guidelines in the world for doctors to follow, if all of them are computed together, the inclusion criteria would add up to only 39% of patients. The majority of 61% patients do not have guidelines. Similarly, there are as many reviews eulogizing coronary interventions in the immediate post infarction period as there are which show them in bad light(1).

Almost all the randomized studies cited in the reviews written, whether from the rich or poor countries, relate to ideal patients with a single intervention at a time, while in practice in real life situations rarely does one encounter patients in such an ideal slot. The practising doctors might have to innovate. More than all that is the bane of poly-pharmacy that doctors have to, per force, practise in many clinical situations. Drug interactions are a big problem and the resulting adverse drug reactions (ADR) rank fourth as the important cause of death in the US(2). What then is the basis of EBM authority?

Modern medicine has become mandatory for emergency use, anyway. On a long term basis, especially in chronic diseases, most of our interventions have been shown in very poor light(3). The quick-fix medical care interventions described above are for the minority that is ill and not for the well majority. The present effort to use medical care methods for all results in much misery and iatrogenic problems.2Doctors strike in Israel recently and, on a couple of earlier occasions in the distant past, did show that when medical interventions came down death rate in the population fell down significantly(4).


1) Hegde BM. To do or not to do-Doctors dilemma Kuwait. Med. J 2001; 33(2): 107-110.
2) Starfield B. Is US medicine the best in the world? JAMA 2000; 284: 483-485.
3) McCormack J and Greenhalgh T. Seeing what you want to see in randomized controlled trials: versions and perversions of UKPDS data. BMJ 2000; 320: 1720-23.
4) Siegel-Itzkovich J. Doctors strike in Israel may be good for society. BMJ 2000; 320: 1561.


No competing interests declared.