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Q J Med 1998; 91:371–374
Commentary
QJM
The rise and fall of EBM
B.G. CHARLTON and A. MILES1
From the Department of Psychology, University of Newcastle, Newcastle upon Tyne, and
1European Institute of Health and Medical Sciences, University of Surrey, Guildford, UK
Introduction
The rise of Evidence-based Medicine (EBM) has been were never properly addressed—nonetheless CE was
widely regarded as a refreshing approach that blewone of the more remarkable phenomena of the
British health scene during the 1990s. Tremendous away cobwebs and let in some light. In particular, CE
mobilized the enthusiasm of people to come to gripsadvances have been made in establishing the EBM
brand name, obtaining massive government funding, with interpreting clinical data for themselves for use
in their own clinical practice.manoeuvring to a position of unchallenged authority
within the NHS managerial and political hierarchy But the advocates of clinical epidemiology were
ambitious of influence, and grew impatient. A signi-(and its priesthood among the BMJ editorial staff)—
and promoting EBM as a marketing slogan for ficant change came when the name ‘Evidence-based
Medicine’ or EBM was coined in 1992.2 Althoughlucrative conferences, courses, books, journals,
people and organizations. the term involves a calculatedly dishonest misrepres-
entation,3 this new nomenclature was an immediateThe ‘fall’ of EBM is rather different; since it
involves a quasi-theological ‘fall from grace’: a loss rhetorical success. EBM effectively labelled itself as
rational, objective and altruistic—while any opposi-of clinical, scientific and educational integrity, even
to the point of a decline into a ‘state of sin’ (if tion was implied to be promoting a practice that is
illogical, self-indulgent and opposed to the evidence.seeking and clinging to power at any costs is seen
as sinful). This moral decline would—in the normal A set of mission-statements was proposed as definit-
ive of EBM: these took the form of platitudes whichcourse of events—be followed in due course by loss
of status, income and power. However, the EBM could not be opposed by any rational person;4 yet
these content-free proclamations served to camou-barnacle may prove difficult to dislodge now it has
a grip on the minds of politicians and managers. flage controversial ways of operating and marginalize
opponents as wicked or crazy.Certainly, the phenomenon is ripe for re-evaluation.
Clinical Epidemiology to EBM—what’s EBM as a tool of management—a
‘quality-assurance’ systemin a name?
Initially, EBM grew as a bottom-up approach to It is doubtful whether such a crude, question-begging
tactic as naming oneself ‘evidence-based’ wouldcontinuing medical education under the name of
Clinical Epidemiology (CE).1 Clinical Epidemiology have had much influence upon clinicians and med-
ical scientists. However, the proponents of EBMwas based upon emphasizing the potential of epide-
miological information for guiding clinical practice. cleverly bypassed doctors and appealed directly to
politicians, health service managers, public healthIn retrospect, the epidemiological emphasis was
exaggerated and its problems and insufficiencies professionals and the newly expanded ranks of
Address correspondence to Dr B.G. Charlton, Department of Psychology, University of Newcastle, Newcastle upon Tyne
NE1 7RU. e-mail: bruce.g.charlton@ncl.ac.uk
© Oxford University Press 1998
B.G. Charlton et al.372
‘number-crunchers’ (epidemiologists, biostatisticians, the role of implicit or unquantifiable factors such as
clinical judgment, experience, qualitative factors,information technologists, health economists, etc.).
Such personnel had emerged in enormous numbers views of patients and the demands of the clinical
consultation. In particular, EBM displays a longas a consequence of the centralizing and regulating
tendency of the NHS reforms, and they were seeking standing tendency towards anti-scientific rhetoric1
which ignores the foundational role of laboratorytools of legitimation.5
EBM was seized upon by managers and their and clinical sciences in the history of therapeutic
innovation and advance.8myrmidons, and promoted with a massive injection
of publicity, money and organizational infrastructure. The misplaced emphasis on large databases as
offering best guidance for clinical practice leads onThe consequence has been an astonishing trans-
formation from the clinically-led approach of CE to to an implicit belief in the primary role of information
and statistics. Consequently, the nature of clinicalthe managerially-led approach of EBM. Instead of a
bottom-up system using epidemiology to inform good expertise has been redefined by EBM. It has tradition-
ally been assumed that the best people for decidingpractice, the NHS bureaucracy has introduced a top-
down system which employs statistical data to define, upon clinical matters are those with clinical training,
experience and a substantive knowledge of healthprescribe, monitor and enforce specific practices
upon clinicians.6 and disease that ideally includes having performed
research in the field. Such experts are usually doctors.It seems likely that NHS management were so
quick to advance EBM because they saw its potential But EBM regards clinical expertise as mainly a matter
of collecting, analysing and summarizing researchas a ‘quality assurance’ tool capable of regulating,
not just medical practice, but the whole of the health done by other people. Hence the final arbiters
of EBM practice are ‘systematic reviewers’ drawnservice. Traditional managerial and audit methods
require a conveniently measurable output, and clin- from biostatistics, epidemiology, health economics
and other ‘Infostat’ disciplines.5 Clinical advice hasical services are notoriously difficult to quantify.
However ‘quality assurance’ audit concentrates not been neatly bypassed and subjected to external
performance criteria. This can be regarded as theon performance but on the system—quality is defined
and measured in terms of the operations of a control latest move in an ‘audit revolution’ which has swept
the UK Public Sector during the past couple ofand feedback system.7
The ‘evidence-based’ movement in the health decades.7
Suffice it to say that there is not a shred ofservice provides exactly such a quality assurance
system. As the ‘implementation’ moves on from evidence to suggest that an understanding of medical
research and its interpretation for practice can beevidence-based medicine, through evidence-based
education, research and development, nursing, reduced to the routine application of checklists and
formulae. However, doctors are notoriously awkwardpublic health and health policy, we are witnessing
the creation of an interlocking system to comprise and intransigent individuals supported by consider-
able professional solidarity—while Infostat techni-an ‘evidence-based’ health service. This would
incorporate all aspects of health service practice, cians are easily trained, deployed and controlled.
Hence the third, and ethical, criticism of EBM. In aand be based-upon a process of standardized mon-
itoring and interpretation of information. The NHS nutshell, EBM involves a takeover of the clinical
consultation by an alliance of managers and theirwould comprise a set of ‘transparent’ and measurable
activities, regulated by audit of the EB system. And statistical technocrats who are empowered to
define ‘best practice’. The upshot is that the EBMsince the only aspect of quality assurance not open
to challenge is the legitimacy of the quality assurance apparatchiks acquire substantive influence over mil-
lions of clinical consultations, but without anysystem itself,7 EBM would permanently be insulated
from criticism. responsibility for the clinical consequences.
In bed with the BMJThe trouble with EBM
Criticisms of EBM are essentially three-fold, and One of the most striking features of EBM has been
the intimate relationship it has forged with the Britishconcern methodology, personnel and the ethical
framework.6 EBM involves the elevation of certain Medical Journal and its editorial staff. More than any
other factor, this has gained EBM doctrines themethodological principles—in particular the large
randomized mega-trial and (more recently) meta- academic credibility they needed to persuade
the NHS hierarchy of their validity.analysis—to ‘gold standard’ status as criteria against
which all other types of ‘evidence’ should be judged. The support of the BMJ for EBM began with
explicit endorsement by the editor and continuedThis doctrine excludes or relegates to inferior status
The rise and fall of EBM 373
with the commissioning of iterative series of ‘how to of the actual EBM group and its satellites (official
and unofficial), the Cochrane Collaboration, the NHSdo it’ articles on EBM techniques such a randomized
trials, systematic reviews, meta-analyses, ‘critical’ Centre for Reviews and Dissemination; but the main
recipients of bounty are the host of researchersreading skills and so on ad nauseam. BMJ champion-
ship has extended to books on the topic, and a employed by university departments and supported
by grants derived from NHS Research andwhole stable of generalist and specialist EBM journals
(from the BMJ’s publishers) which have been advert- Development, Health Authorities and the Department
of Health.ised using the BMJ editorial columns. BMJ-endorsed
conferences have been organized to promote the All this after just a few years. The prospect of
grabbing a thick slice of this still-expanding cake hasimplementation of EBM policies.
EBM and BMJ got into bed together—both ideolo- surely been a crucial factor in doctors acquiescing
to EBM—and deterring overt criticism. Perhaps thegically and financially—in a way and to a degree
which is unprecedented. It is also astonishing, given fear of alienating a rich source of patronage could
account for the otherwise inexplicable mismatchEBM’s pronounced pro-managerial and anti-clinician
stance and the BMJ’s proper role as the main organ between the near-universal, privately-expressed sus-
picion of EBM among clinicians, and the scarcity ofof British medical opinion. The BMJ now devotes
massively disproportionate attention to the views of published articles expressing this viewpoint?
a minority lobby of largely non-medical opinion.
Indeed, the whole publication policy of the BMJ has
shifted towards ‘second-order’ publications on statist-
Beyond EBM
ics, epidemiology, health economics, management,
policy and politics, health promotion—anything, it
EBM stands revealed as statistical rather than scient-
seems, except for articles by or for clinicians. In
ific; its success more to do with managerial domin-
essence, the BMJ has become the house journal of
ance than medical desirability. Any modest initial
the EBM workforce.
benefits have long since been outweighed by struc-
tural damage, wasted expenditure, and clinical power
without clinical responsibility. EBM has advanced
audit into the consultation, and offers the prospect
Above criticism
of an ‘evidence-based’ health service forcibly unified
Perhaps the most worrying feature of EBM, and the
under a single ‘quality assurance’ system—easily
one which most clearly betrays its non-scientific
regulated by politicians, bureaucrats and their statist-
nature, is the fact that its advocates do not answer
ical technicians.4,5,7
criticism. A magisterial attitude of lofty disdain for
Beyond EBM there lies a whole world of good
contradictory viewpoints is the norm in government
practice and real evidence which has been largely
circles where power is asymmetrically distributed
forgotten or obfuscated by rhetoric. Alternative, more
and the agenda is controlled. Similarly there has not
effective models of health service organization are
been any substantive debate about EBM, merely a
available—including self-regulating professionals
one-sided onslaught of NHS/BMJ-subsidized propa-
embedded in a facilitating administrative structure;
ganda. Dissenting views are muzzled, marginalized,
while superior modes of clinical investigation would
met by non-sequiturs, or disappear into an echoing
emphasize rigorous clinical science, close observa-
void. Backstairs wheeling-and-dealing has substituted
tion of practice including individual case studies,
for public discussion.
whole population studies and representative popula-
Avoidance of debate is related to the fact that EBM
tion sampling—with mega/meta-population epidemi-
has moved directly from being a ‘bright idea’, to the
ology again relegated to its proper, subordinate, role
implementation of this idea—leaving out the usual
of precise measurement.4,5,8,10
period of critique, evaluation and testing. The pros-
The time is ripe for the ‘evidence-based’ mantra
elytizing zeal of EBM proponents has attracted
to be silenced and dissenting voices to be heard.
comment.9 EBM enthusiasts see its benefits as self-
If EBM does not fall spontaneously, it may need to
evident; hence any disagreement is merely indicative
be pushed.
of a failure to understand—or else due to a more
sinister determination to practise medicine in a non-
evidence-based manner.
References
It is hard to estimate the number of people who
are already employed on EBM-related activities, or
1. Sackett DL, Haines RB, Tugwell P. Clinical epidemiology.
benefit financially to a substantial extent, but the
Boston, Little, Brown & Co, 1985.
trough is deep and its beneficiaries probably exceed
2. EBM Working Group. Evidence-based medicine. JAMA
1992; 268:2420–5.
ten thousand in number. There are direct employees
B.G. Charlton et al.374
3. Shahar E. A Popperian perspective of the term ‘evidence- 6. Charlton BG. Restoring the balance: evidence-based
medicine put in its place. J Eval Clin Pract 1997; 3:87–98.based medicine’. J Eval Clin Pract 1997; 3:109–16.
7. Power M. The audit society: rituals of verification. Oxford,
4. Miles A, Charlton BG. Evidence-based medicine—a
Oxford University Press, 1997.
critique: 1 & 2. In: Miles A, Lugon M, Bentley P, eds.
Effectiveness and Efficiency in Clinical Practice.
8. Charlton BG. Natural kinds, natural history and the
London, Radcliffe Press, in Press.
clinician-researcher. Q J Med 1997; 90:707–9.
9. Lancet (editorial). Evidence-based medicine in its place.
5. Charlton BG. Infostat, cargo-cult science and the policy
Lancet 1995; 346:785.
sausage-machine: a critique of rationalist management in
the reformed National Health Service. In: Miles A, Lugon M, 10. Charlton BG. The future of clinical research: from megatrials
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