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© 2003 European Association of Cardio-Thoracic Surgery
Writing off evidence in evidence-based medicine?Department of Cardio-vascular Surgery, Centre Hospitalier Universitaire Vaudois, CHUV, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
* Tel.: +41-21-314-2280; fax: +41-21-314-2278 Evidence-based medicine is a very popular issue in the recent medical literature. As a matter of fact, PubMed lists today, on October 26, 2003, for the term ‘evidence-based medicine’ 12685 references. The first papers about this topic appeared in November 1992 [1], and more than 12590 or >99% were published during the last 8 years, i.e. after 1995. There are various possibilities to explain such a development, e.g. medicine prior to 1995 was not based on evidence, nor it was not recognized to be based on evidence, or the term evidence has changed its meaning. As it is not exactly flattering for most of us to be identified as practicing medicine without evidence, it might be worth trying to understand what has happened. In a Dictionary of the English Language published before the issue raised here [2], evidence is defined as (1) ground of belief; that which tends to prove or disprove something; proof. (2) something that makes evident; an indication or sign: ‘his flushed look was visible evidence of his fever’. (3) Law. data presented to a court or a jury in proof of the facts in issue and which may include the testimony of witnesses, records, documents, or objects. (4) in evidence, plainly visible; conspicuous: ‘the first signs of spring are in evidence’... However, the term ‘evidence’ is derived from the Latin word ‘evidentia, (-ae, f)’, a word which is translated best by ‘illustration’. Obviously, something has happened to the meaning of ‘evidence’ since the Roman days and ours. In the famous Encyclopédie ou dictionnaire raisonné des sciences, des arts et des lettres published by M. Diderot et M. D'Alambert in the second part of the 18th century [3], the term ‘evidence’ is described as a certainty which is so clear, and so manifest by itself, that our minds cannot refuse it. In contrast, earlier encyclopaedias like the Dictionnaire de Moreri [4], which was published in the first part of the 18th century, does not mention the term ‘evidence’. Interestingly enough ‘excellence’ is the word cited in alphabetical order which is closest to our search term. Certainly, the thoughts of philosophers and scientists, like René Descartes (in Latin Renatius Cartesius, born in 1596 in La Haye-Descartes, Tourraine, France), had a major influence on the definition of terms. In his Principes de la philosophie we can read in the second part about the ‘Principles of material things’ [5], that he believes the truth to be present for those things we can feel, in the sense that they excite us to perceive them, e.g. substances with length, largeness, and deepness. In German, the term ‘Evidenz’ is used for the highest degree of certainty as well as for a higher philosophical understanding, which cannot be proven by exhibits. For a long time examples from Euclid's geometry based on axioms (e.g. ‘there is only one straight line between two points’: Euclid, Greek mathematician, who taught in Alexandria around 300 BC) were used to illustrate the latter view, which in turn, received a serious blow with the advent of the non-Euclidian geometry [6]. For surgical practice, the current debate on evidence-based medicine is a major issue, because double-blinded, randomized controlled trials have been allotted the highest level of evidence. As an operation has to be performed by somebody, who is able to do it and knows what he is doing, this highest level of evidence cannot be reached for most surgical procedures by definition (random allocation of blind surgeons not being very popular with patients). However, it has to be accepted that the application of successful interventions for otherwise fatal conditions does not require evaluation by randomized trials [7]. A randomized trial for ruptured aortic aneurysms undergoing either surgical repair (study group) or tender loving care (control group) would certainly not find many participating patients giving full informed consent for participation in the control group. Obviously, this type of therapeutic problem speaks so much for itself that we have to accept it [3]. It appears here quite evidently that the larger a trial has to be for reaching a pre-defined level of evidence, the lesser the latter probably is. Likewise, in emergency medicine it may be unethical to wait for a randomized trial [8] if an effective therapy or a more efficient new organizational mode becomes available. Nevertheless, there are a number of problems in surgery, and especially cardio-vascular and thoracic surgery, where no consensus has emerged until today, and opposing opinions prevail. This type of issue has been taken up by Joel Dunning for systematic review of the existing literature and grading of the compiled results as ‘Best BETS in cardio-vascular and thoracic surgery’ [9]. Interactive Cardiovascular and Thoracic Surgery is pleased to announce the new format of ‘Best BETS’ for prepublication on the web and public discussion at www.icvts.org, prior to traditional printing of both ‘Best BETS’ with YOUR comments! doi:10.1016/S1569-9293(03)00237-8
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