Commentary

Evidence-based medicine: It’s not a cookbook!

Current Psychiatry. 2021 May;20(5):34-38,46 | doi:10.12788/cp.0124

References

1. Citrome L. Evidence-based medicine: it’s not just about the evidence. Int J Clin Pract. 2011;65(6):634-635.
2. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312(7023):71.
3. Citrome L. Think Bayesian, think smarter! Int J Clin Pract. 2019;73(4):e13351. doi.org/10.1111/ijcp.13351
4. Sackett DL. Evidence-based medicine. Semin Perinatol. 1997;21(1):3-5.
5. Cohen AM, Stavri PZ, Hersh WR. A categorization and analysis of the criticisms of evidence-based medicine. Int J Med Inform. 2004;73(1):35-43.
6. Dutton DB. Worse than the disease: pitfalls of medical progress. Cambridge University Press; 1988.
7. Maggio LA. Educating physicians in evidence based medicine: current practices and curricular strategies. Perspect Med Educ. 2016;5(6):358-361.
8. Citrome L, Ketter TA. Teaching the philosophy and tools of evidence-based medicine: misunderstandings and solutions. Int J Clin Pract. 2009;63(3):353-359.
9. Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements (Residency). Revised February 3, 2020. Accessed March 30, 2021. https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2020.pdf
10. Citrome L, Ellison JM. Show me the evidence! Understanding the philosophy of evidence-based medicine and interpreting clinical trials. In: Glick ID, Macaluso M (Chair, Co-chair). ASCP model psychopharmacology curriculum for training directors and teachers of psychopharmacology in psychiatric residency programs, 10th ed. American Society of Clinical Psychopharmacology; 2019.
11. Citrome L. Interpreting and applying the CATIE results: with CATIE, context is key, when sorting out Phases 1, 1A, 1B, 2E, and 2T. Psychiatry (Edgmont). 2007;4(10):23-29.
12. Citrome L, Stroup TS. Schizophrenia, clinical antipsychotic trials of intervention effectiveness (CATIE) and number needed to treat: how can CATIE inform clinicians? Int J Clin Pract. 2006;60(8):933-940. doi: 10.1111/j.1742-1241.2006.01044.x
13. Citrome L. Dissecting clinical trials with ‘number needed to treat’. Current Psychiatry. 2007;6(3):66-71.
14. Goldberg JF, Freeman MP, Balon R, et al. The American Society of Clinical Psychopharmacology survey of psychopharmacologists’ practice patterns for the treatment of mood disorders. Depress Anxiety. 2015;32(8):605-613.
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Training medical students and residents

Although there is some variation in how EBM is taught to medical students and residents,^7,8 the expectation is that such education occurs. The Accreditation Council for Graduate Medical Education requirements for a residency program state that “the program must advance residents’ knowledge and practice of the scholarly approach to evidence-based patient care.”⁹ The topic has been part of the American Society of Clinical Psychopharmacology Model Psychopharmacology Curriculum, but only in an optional lecture.¹⁰ The formal teaching of EBM includes how to find relevant biomedical publications for the clinical issues at hand, understand the different hierarchies of evidence, interpret results in terms of effect size, and apply this knowledge in the care of patients. This 5-step process is illustrated in Figure 2⁸. See Related Resources for 3 books that provide a scholarly yet clinically relevant approach to EBM.

Continuing medical education

Most Current Psychiatry readers have been out of residency for some time and have not necessarily been exposed to the philosophy and tools of EBM. It may be easier to simply jump in and learn about effect sizes and then use information already curated and apply this knowledge. A good starting point is a recap^11,12 of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) for schizophrenia that answers the questions: “How large is the effect being measured?” “Is it clinically important?” and “How are we dealing with a result that may be statistically significant but irrelevant for day-to-day patient care?” Number needed to treat (NNT) and number needed to harm (NNH) can help explain this by allowing one to judge the clinical significance of a statistically significant result.¹³

Practical applications

There are common clinical scenarios where evidence is ignored, or where it is overvalued. For example, the treatment of bipolar depression can be made worse with the use of antidepressants.¹⁴ Does this mean that antidepressants should never be used? What about patient history and preference? What if the approved agents fail to relieve symptoms or are not well tolerated? Available FDA-approved choices may not always be suitable.¹⁵ The Table illustrates some of these scenarios.

Evidence-based medicine: It’s not a cookbook!

References

Training medical students and residents

Continuing medical education

Practical applications

Pages

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