Teaching evidence-based medicine: Caveats and challenges

Evidence-based medicine (EBM) is an important new paradigm of the medical p rofession. While the quantitative approach of EBM has its place, clinical m edicine must take into account many subtleties that EBM fails to consider. In this article, the authors describe three caveats to this quantitative ap proach: (1) the detection of "maybe disease" (physiologic, anatomic, or his tologic abnormalities that may not ever be overtly expressed in the patient 's lifetime) inflates apparent diagnostic test performance; (2) probability revision is valuable primarily as an exercise to gain qualitative insights ; and (3) patients are likely to be interested more than just central tende ncies in making treatment decisions. They then consider some challenging qu estions facing clinician-educators: how do they prepare students for situat ions where there is an absence of rigorous evidence? Should they teach stud ents that the burden of proof lies in demonstrating efficacy or in demonstr ating ineffectiveness? And what should they tell students about when to see k evidence to aid diagnostic and treatment decisions?