Examining the assumptions of evidence-based medicine.

Evidence-based medicine (EBM) has had enormous impact on clinical medicine, attracting both converts and detractors. The basic premise, that clinical decisions should be made on evidence which is as sound as possible, appears unassailable. Why, then, has the idea stimulated such controversy? In this article, I examine six assumptions of EBM, and point out how these assumptions are frequently open to challenge. Finally, I make specific recommendations for future activities to ensure that the strategy achieves an appropriate role in health care decision-making. These include: (1) conducting research to establish the effectiveness of EBM; (2) incorporating (as they apparently are) more holistic perspectives on the nature of evidence; (3) moving (as they are) toward the use of expert reviews and away from a focus on the skilled individual practitioner; (4) examining the literature on continuing education to devise more appropriate dissemination strategies, including, specifically, educational influentials; and (5) making specific attempts at conciliation and seeking common ground with other schools of thought.