Professor Andrew Cockburn

Professor in Toxicology

Evidence-based medicine (EBM) aims to apply evidence gained from research to parts of medical practice. Within clinical medicine it looks at the quality of evidence relevant to the risks and benefits of medical treatments, including pharmaceutical treatments and practical procedures. The aim being that the physician will use this in conjunction with his clinical acumen and the patients wishes to determine an individuals best course of treatment.

Professor Andy Adam

Professor of Radiology

Evidence is what distinguishes medicine from quackery. Evidence is what allows us to practice safely, to improve methods that work and to discard ones that are ineffective. Patients trust doctors because they believe that they will act in their best interests: implicit in this trust is the expectation that they will base their recommendations on evidence. However, a doctor who thinks that we understand everything about the human body is either arrogant or a fool. We must be prepared to review unexpected results and to reinterpret evidence, as that is what will allow medicine to develop and improve. After all, Lord Kelvin thought that X-rays were a hoax. And if anyone had suggested treating duodenal ulcers with antibiotics when I was a medical student he would have been thought a crank. Doctors should be scientists, but should keep an open mind.

Carolyn Johnson

Research Assistant in Reproductive Biology

Both verification and justification of medical treatment are incredibly important, if only to ensure the safety of treatments offered to patients. A doctor would never prescribe an untested conventional drug to a patient - it would be a wholly irresponsible act as the actions of the drug would be unforseeable. There is no reason therefore to assume that a homeopathic remedy is any less dangerous than a conventional drug. Both need to be tested in the same rigorous manner before being offered to the public.

Professor Sir Colin Berry

Emeritus Professor of Pathology

As a medical student I assisted at many radical mastectomies. This mutilating operation was carried out in the belief that the best hope of cure for cancer of the breast was to “get ahead of the tumour”. It should thus be excised with an adequate margin; this might necessitate the removal of the entire breast, underlying muscles and even part of the chest wall. As the tumour was known to spread by lymphatics to local lymph nodes, these were usually removed. In terms of our understanding of the disease in the late 1950’s, this was not unreasonable therapy even if the left the woman with a swollen arm and the inability to use that arm effectively. What was unreasonable was that no-one, until around that time, had looked to see if it was good treatment – in particular, whether this degree of surgical aggression was necessary. Could more conservative treatment be as effective? A better understanding of tumour biology (the realisation that getting ahead of the tumour is unrealistic since some tumours would have metastasised via the blood when at a very early clinical stage) and moves to conserve the breast, to look critically at the pattern of lymph node involvement and to be selective about what might be done together with the advent of highly selective chemotherapy has transformed the situation for most women. It is surprising, in retrospect, that for perhaps 30 years the radical solution was assumed to be the best one. It was the development of the clinical trail that enabled surgeons to be confident that they could do the best for their patients on the basis of carefully collected data on survival and quality of life – the old mantra could not be abandoned without evidence.

Daniel Mortlock

Research Associate in Astrophysics

The scientific method has repeatedly proved the most powerful way in which human beings can understand the natural world, and one of its many benefits is the abundant success of evidence-based medicine. Even with the complexities of a human being and mysteries of the placebo effect, most medicine operates at a simpler level: clean a wound and it will not become infected; if it is already infected then antibiotics will kill the harmful bacteria. In both cases the treatment is repeatable and, critically, the mechanism understood. Applying these scientific principles while treating patients with respect and compassion should be at the heart of the healthcare system.

Daniella Muallem

PhD Student in Physiology

Patients often don’t understand what evidence means. Evidence-based medicine is that which does the most good for most people. This means that it may not be the right medicine for everyone, but given the choice between that or a medicine which has no evidence base, I would go for the former every time. Any drug that has an effect will also have side effects. Patients have to consider the negative side effects of a treatment and weigh them up against the negative effects of a disease. Alternative therapies are good when there is no alternative in conventional medicine and there is no risk of death or permanent disability from the illness. However, for many patients there is a stigma attached to taking conventional drugs; I’ve seen people suffering permanent disability from much less severe forms of disease than my own, because they relied entirely on alternative therapies. Practitioners of complementary alternative medicine never offer an explanation if the therapy does not work. I’ve been told that it was my fault, for ‘not being in the correct meditative state’. Similarly they never admit that there’s some things that alternative medicine cannot treat. Alt. Medicine practitioners have a poor concept of what constitutes evidence. Pharmaceutical drugs are constantly improving the quality of life for people with disease, and continually improve upon themselves. For most diseases, I would much rather get sick with them today than twenty years ago.

Professor David Coggon

Professor of Occupational and Environmental Medicine

As a patient, I personally would always wish to receive treatment that was compatible with the best available scientific evidence.

Professor Edzard Ernst

Professor of Complementary Medicine

It is difficult to answer why evidence-based medicine is important to me as there is no alternative. If we do not use evidence as the basis of our decisions then what else is there? Intuition, experience – both have been used in the past and both have failed dismally. So I don’t see an alternative to evidence-based medicine. Those who attack evidence-based medicine for its ‘cookbook’ or ‘straitjacket’ decisions clearly have not understood what it is.

Emma Louise Millar

PhD Student in Molecular Virology

I generally find that if evidence based medicine comes up in a discussion, a comment swiftly follows along the lines of, 'isn't that just common sense?'. Exactly.

Professer Gustav Born

Emeritus Professor of Pathology

Everything that has improved the human condition is based on evidence. And evidence based medicine is part of that.

My grandmother died in 1886 when my dad was two years old, from gallstones. Only a few years after she died, a Swiss surgeon, Theodor Kocher, invented the operation which stopped people dying of it. Recent advances allowed my wife to have her gallbladder out by a keyhole operation. Absolutely amazing. I took her to hospital one afternoon, she had the operation and left after lunch the following day; all successful evidence-based medicine.

Ian Mabbet

PhD Student

The reason I support evidence based medicine is simple. Whenever I make any decisions in life I try to do them based on an estimate of the outcome. As a scientist and engineer I trust things which have been shown to work through controlled trials, with sensible proposed mechanisms that have been peer reviewed by other experts then published. <br><br> You wouldn’t want to buy a house when economists tell you that you may lose money on it and you wouldn’t try to fix a car with a blown head gasket by bathing it in an extremely dilute solution of engine oil, so why treat your body any differently? Unless the outcome can be proven to work, or the reasons behind the treatment make absolute sense, then I will remain sceptical.

James Reeve

PhD Student in Chemistry

We cannot rule out the fact that any substance may have a medicinal quality. However, every substance that is sold as a remedy must be exposed to the same double-blind clinical trials that are most strictly imposed upon newly developed pharmaceuticals. We must not give value to the logical fallacy that substances have inherent worth as medicines if used to treat a malady in days gone by.

Johnny Kelsey

PhD sudent in Systems Biology

I feel a certain amount of despair that NHS funding is used to support homeopathic and other alternative treatments, which have absolutely no evidence to support their claimed efficacy, channelling precious resources away from research where we can show that medicine can make a difference.

Professor Julian Ma

Professor of Molecular Immunology

"Evidence-based Medicine" is not a product or a therapeutic procedure, it is a philosophy upon which modern medicine must be based. It is what makes the practice of medicine, a science. Without evidence no medical intervention can ethically be rationalised. In the future, medicine will continue to make great strides, and there will be setbacks too, but only through this correct approach to medicine, can we learn and understand why we have made great or wrong decisions.

Dr Julie Huxley-Jones

Research Scientist

Every day millions of people are treated with medicines that wouldn't exist without science. Evidence-based research has fast-forwarded how we find treatments, from what was just chance discovery to targeted generation of medicines. Our health has improved, how we recover has changed, life expectancies are increased and ultimately lives have been saved. Now through vaccination programmes we can prevent getting the illness in the first place. But most importantly evidence-based medicine can demonstrate how, where, when and why it works.

Dr Keith Baker

Research Scientist in Knowledge Management

Barely a day goes by without science being mis-reported in the media and by individuals and groups pursuing their own agendas. Public confidence in any conclusions drawn from scientific research can be destroyed overnight by the words of those seeking a few column inches, a few votes, or profits from pseudo-scientific 'products' and 'services'. Rarely are the offenders called to defend themselves, yet never does a day go by without scientific research itself being defended. For the sake of human lives that imbalance needs correcting.

Professor Kevin Kerr

Professor of Microbiology

When cholera raged in Britain in the 19th Century, medical orthodoxy dictated that treatments such as hot mustard poultices along with encouragement of fluid loss through purgatives, emetics and bleeding were the only ways to save a cholera victim. By following the textbooks of the time, physicians caused immeasurable harm and it is ironic that those who challenged established opinion by recommending fluid replacement – which evidence-based medicine has since shown to be highly effective treatment for cholera - were denounced as quacks. As cholera created anxiety for the population in the 19th Century so healthcare-associated infections, such as MRSA, are also a cause of concern for the public of today. Action is clearly needed to curb these infections, but although there is an urgent need for solutions to the problem, we must strive to ensure that these are soundly evidenced-based.

Marc Woolfall

Research Scientist in Detergents

EBM is fundamental to progress in medicine. It is easy for people to forget just how bad life was in the past without medicine to help us: polio, smallpox, the plague, measles, mumps, etc. The use of evidence is the only way that we can tell whether something is effective or not. In medicine it is surprisingly easy to believe that treatments work even when they do not. If we don't test treatments properly we are only fooling ourselves and will never be able to improve.

Matthew Child

PhD Student in Parisitology

By its very nature science is evidence based and evidence-based medicine stands as an early pinnacle of human achievement. It represents the application of knowledge gained through observation and testing, and these principals are the keystones of modern medical theory. Evidence is fundamental to this as it facilitates the continual remodelling of our hypotheses and the progressive development of our understanding. Medicine which is not based on evidence is simply not scientific and worse, is dangerous as it permeates society and propagates myth and misunderstanding. Sadly this undermines the very foundations of medicine, which seeks to improve our lives through rational, hypothesis led and evidence backed research. Every effort must be made to ensure that awareness is drawn to the conceptual incoherence of such illogical approaches in order to dispel these myths before they have the chance to become entrenched.

Professor Raymond Tallis

Emeritus Professor of Geriatric Medicine

Medicine is always based on some kind of evidence. The trouble is most evidence is highly unreliable, and there are lots of ways to go wrong so that you mistakenly believe that your medicine has done more good than harm. These include: attributing to the medicine improvements that are due to natural recovery. In addition, there is recall bias, by which you selectively remember or recall those cases in which there seems to have been improvement and forgetting those in which treatment has proved useless or harmful. This bias potentially affects patients, their doctors and even medical journals. The lack of an appropriate method for distinguishing beneficial from harmful treatments means that medicines over the last 3,000 years have been mostly dangerous or useless.

Things that work in theory, no matter how good the theory, might not work in practice.

EBM is about retaining those treatments that genuinely produce more good than harm and are genuinely cost effective, and weeding out those that are ineffective or harmful or not cost-effective. For that you need a methodical approach, that rules out the play of chance or active bias, particularly those introduced by those who have a vested interest in promoting a particular medicine.

The great breakthrough was the development of a randomised control trial. Though not always applicable, and though the results apply to populations of patients and not always particular patients, it is the best weapon in trying to identify treatments that are likely to work in a majority of people with a particular condition.

Randomised control trials eliminate bias; first of all neither patient or doctor knows whether it’s a new treatment or old that’s being received, so the placebo effect is factored out. Secondly, the people receiving the treatment are matched, so you’re not going to get a false positive from having patients with a better prognosis being given the new treatment and those with a worse prognosis being given the old treatment.

The randomised controlled trial is only the first step of the journey to EBM. There are several steps from there which have really only been apparent the last 30 odd years:

1. The development of mega-trials, involving hundreds, thousands, and even tens of thousands of patients, large enough to pick up small but real effects that are not due to the play of chance.
2. The next step is systematic review, which brought together information about trials because one trial sometimes isn’t enough. And this would include not only trials that were published but also those that were not published (if they can be accessed). This gets rid of a different source of bias, which is publication bias, which tends to favour the publication of positive results.
3. The next and most recent step is the meta-analysis, which goes back to the original data of all the trials and pools them as far as is possible, so long as the patient groups are comparable, and similar outcome measures are used. While using EBM this way we’re not gong to get absolute truth immediately, it will give us a very robust basis for the choice of our treatments. When it comes to actual clinical practice, evidence based medicine is necessary condition for good clinical decision making. But it may not be sufficient. It doesn’t take away clinical judgement.

From 1970, when I started practising, to 2005, the age related incidence of cardiovascular disease fell to a third, and the pace is quickening. This is a result of guidelines based on clinical trials. The deaths from coronary heart disease below 65 fell by 54% in the decade of the nineties. Clearly this isn’t due to changes in social circumstance – it’s due to specific interventions.
Much of that is very patiently put together from the guidelines for prevention, acute treatment, and post acute treatment.

The randomised control trial came to existence 1940s, mega-trials in the 70s-80s. Systematic analysis and meta-analysis developed over the last 20 years, promoted in particular by the Cochrane Centre. In parallel with this has been a sea change in the education of doctors and the attitude of doctors: We now recognise the place for expert opinion: it’s being able to use the data available and use it wisely. It is not about having one’s own opinion on the basis of clinical impressions, hearsay or personal authority.

So that is why I’m madly enthusiastic about EBM, and because will probably save my life. It also represents a signal triumph of humanity over its own propensity to bias, to deception and self-deception, and to blind belief in the authority of those who profess wisdom.

Iain Chalmers has done more than anyone to promote systematic review. EBM is the opposite of arrogance, in two senses – that my personal opinion is not priceless, and that I will always be prepared for new evidence and to change my opinions.

Rehana Jawadwala

Reseach Scientist in Sports Sciences

Many of the times we associate evidence based medicine with randomised, double blind, clinical studies and meta-analysis. But it is far more than that. It involves judicious use of the current best evidence in the practice of medicine, which is fundamentally distinguished by the need for judgement in the face of uncertainty. Doctors’ up-to-date knowledge and skill is not only complimentary to their expert judgement but it provides the best safety net we have for accurate prognosis and precise therapeutic strategies. In an age where deference is dead and league tables are the norm, doctors must be clearer about what they do and how and why they do it. Relying on an evidence-based knowledge is the only way to be certain of that.

Professor Richard Sharpe

Professor in Reproductive Sciences

What most people fail to realise is that research operates at 'the frontiers of ignorance'. What is in front is unknown and we use our current understanding to hypothesize what may be happening. A hypothesis is therefore based on facts but it is otherwise no more than 'crafted imagination'. The hypothesis must be tested to find out which aspects are correct and which are wrong (hypotheses are virtually never correct). This is the basis of evidence-based medicine and is the foundation of good science. This process enables ideas and imagination to be converted into useable facts.

Dr Robin Lovell-Badge

Research Scientist in Developmental Genetics

Evidence is not just about solving crimes; it is also about finding the best cures for diseases. Cures that are both safe and show real benefit. You would feel aggrieved if you were prosecuted without evidence, so why disregard evidence when looking for treatments?

Dr Ronald Bishop

Research Scientist

I would rather trust procedures based on semi-objective evidence than on subjective opinion/prejudice/historical inertia to help keep me alive!

Sarah Whitehead

PhD Student in Molecular Biology

Research is an essential part of the future of medical treatment. Evidence based medicine offers the opportunity to learn about how our bodies work and use this knowledge to save lives and greatly enhance quality of life. Due to the high risks involved in the development of novel treatments thorough understanding of the mechanisms of action of new drugs or treatments is crucial. What better way to combine the pursuit of knowledge with helping the world?

Steve Churton

President, Royal Pharmaceutical Society of Great Britain

Pharmacy is a unique profession being deep rooted in science. Pharmacy has largely been central to the generation of evidence for the development of new medicines, technologies and delivery systems for medicines and historically, the remote use of medicines. Evidence and the generation thereof have traditionally been integral to the science of pharmacy. More recently however the profession has formerly emerged as a health care profession applying its specialist science knowledge to direct clinical management of patients, with advanced roles now encompassing prescribing and symptom management. Here the evidence on the impact of this changing role on patient outcomes is less robust. The profession of Pharmacy is at a defining moment and now more than ever there is a need to both build the evidence base and to integrate that evidence into practice. Both the generation of evidence through primary research and the use of evidence in practice forges inter professional allegiances, contribute to professional standards and competencies and ultimately provide patients with access to safe and effective treatments and services. The combination of a strong science base with a new and emerging platform of evidence for practice is critical for the future of the profession.

Tom Ritman-Meer

PhD student in Molecular Plasmonics

Evidence based medicine matters to me because drug based remedies are produced by private companies operating for profit. I have no objection to the selling of a drug where there is a body of biological evidence that that drug can interfere with the chemical processes of the body to bring positive effect. I do however, object when people make money out of the public lack of knowledge regarding the scientific method and offer products which have not been rigorously shown to produce any positive effects, since this is tantamount to fraud in my view and may even be dangerous."

Professor Vincent Marks

Emeritus Professor of Biochemistry

Just because a lot of people believe in something does not make it true. Evidence-based medicine is concerned mainly with treatment by proving that claims for the effectiveness of medicines are based on science and established by properly conducted clinical trials and not on mythology, folk-lore or pseudo-science. Correct diagnosis is the key to modern evidence based medicine; even the most effective medicines will only work when given to patients with the correct diagnosis. Diagnosis depends on an understanding of a patient’s illness (pathology) and the application of rigorously tested and scientifically proven diagnostic procedures. False claims made for procedures such as chelation tests, hair analysis and IGG (immunoglobulin) tests for food allergy with tenuous links to science as well as those that are pure fantasy such as Vega testing, Iridology and Crystal Ball Gazing are designed to deceive. Unlike genuine diagnostic tests they are not based on science and do not withstand critical scrutiny; no data establishing their validity, including their error rate, will have been published in peer reviewed literature. Collectively false diagnostic tests are nothing but scams that have ruined people’s lives and deceived many more into undertaking unproven, sometimes dangerous and always costly "therapeutic" interventions for non-existent illnesses or those that should have been treated properly by EBM.

William Blair

Research Scientist in Biomedicine

I have become more concerned about the need to emphasise the importance of evidence-based medicine recently. It is not just the "general public" I'm worried about. I work for the NHS as a biomedical scientist in microbiology and like all my colleagues must have a biomedical science degree and be state registered. We have all sat exams in subjects including physiology, biochemistry, microbiology etc. Yet even here, with a relatively high level of scientific education, I work with people who seem to have put aside this knowledge and embraced "alternative" medicine, despite the fact it completely contradicts everything they have learned. If these people, who I get on well with on an everyday basis can reject the scientific method and cannot see the need for evidence based medicine - what hope does everyone else have, who rely on the media for their information?