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Bridging the Gap Nao E Eiã Historiográfica How to cite this article: Lapa TG, Rocha MND, Filho NMA, Dias ALM. A brief history of evidence-based medicine. J Évid-Based Healthc. 2019;1(2):125-130. doi: 10.17267/2675-021Xevidence.v1i2.2485 A brief history of evidence-based medicine Uma breve história da medicina baseada em evidências 1 2 Bridging the gap Tânia Guimarães Lapa , Marcelo Nunes Dourado Rocha , Naomar Monteiro Almeida Filho3, André Luis Mattedi Dias4 1Corresponding author. Federal University of Recôncavo da Bahia, Federal University of Bahia. Santo Antônio de Jesus/Salvador, Bahia, Brazil. ORCID: 0000-0003-4847-5868. [email protected] 2Federal University of Bahia. Salvador, Bahia, Brazil. ORCID: 0000-0001-8766-3939. [email protected] 3Federal University of Bahia. Salvador, Bahia, Brazil. ORCID: 0000-0002-4435-755X. [email protected] 4Federal University of Bahia. Salvador, Bahia, Brazil. ORCID: 0000-0002-3943-0951. [email protected] RESUMO | INTRODUÇÃO: Medicina baseada em evidências ABSTRACT | INTRODUCTION: Evidence-based medicine is (MBE) é uma das mais difundidas tendências contemporâneas one of the most widespread trends in contemporaneous da educação médica. Propõe bases científicas não apenas medical education. It proposes a scientific framework not para a educação médica, mas também para a pesquisa e a only for medical training, but also for medical research and prática médica. Entretanto, o conhecimento sobre as raízes e practice. However, knowledge about EBM roots and historical o desenvolvimento histórico da MBE não é usual no âmbito developments is not usual within Brazilian medical community. da comunidade médica brasileira. De fato, a maioria das Indeed most common publications for non specialists medical publicações dirigidas para leitores médicos em geral, sob a readers, like handbooks and tutorials papers on EBM, are not forma de tutoriais e manuais, não oferecem conhecimentos sufficiently rich for providing historical knowledge.OBJECTIVES: históricos suficiente sobre a MBE. OBJETIVOS: Apresentar To present a brief narrative of the historical development of uma narrativa breve do desenvolvimento histórico da MBE. evidence-based medicine. METHODS: Historiographical review MÉTODOS: Ensaio de revisão historiográfica. MATERIAIS: essay. MATERIALS: Primary and secondary sources on the Fontes primárias e secundárias sobre a história da MBE. history of EBM. RESULTS: As EBM founder, David Sackett stated RESULTADOS: Como fundador da MBE, David Sackett criticou against clinical decisions based solely on physicians authority as decisões clínicas baseadas na autoridade e na intuição and intuition achieved by long term clinical experience and de médicos, adquiridas da longa experiência clínica e do pathophysiological knowledge. Paradoxically, in his retiring conhecimento fisiopatológico. Paradoxalmente, na sua carta de letter, Sackett alleged that his own prestige and authority could aposentadoria da MBE, Sackett alegou que seu próprio prestígio retard the scientific advance of EBM. CONCLUSION: Since the e autoridade poderiam comprometer o avanço científico da early 2000’s, critical appraisal, systematic reviews and clinical MBE. CONCLUSÃO: Desde o início do novo milênio, avaliações practice guidelines has merged in a unified approach that críticas, revisões sistemáticas, diretrizes e protocolos para a characterizes current practice in EBM. prática clínica foram reunidos numa abordagem unificada que caracteriza a prática contemporânea da MBE. KEYWORDS: Evidence-Based Medicine. History of Medicine. Medical Education PALAVRAS-CHAVE: Medicina Baseada em Evidências. História da Medicina. Educação Médica. Submitted 08/12/2019, Accepted 10/02/2019, Published 10/18/2019 J. Évid-Based Healthc., Salvador, 2019 December;1(2):125-130 Doi: 10.17267/2675-021Xevidence.v1i2.2485 | ISSN: 2675-021X In 1964, a report from the Canadian government The general scientific problem with which we are recommended the creation of a new medical school at primarily concerned is that of testing a hypothesis that a McMaster University, Ontario, that should introduce certain treatment alters the natural history of a disease a new approach to medical education, current for the better. The particular problem is the value of medical school programs were evaluated out-of-date. various types of evidence in testing the hypothesis. The oldest, and probably still the commonest form of This new approach was based in the introduction evidence proffered, is clinical opinion. This varies in of clinical epidemiology and biostatistics in the value with the ability of the clinician and the width of medical program also the medical curriculum would his experience, but it value must be rated low, because be based on valid outcomes of medical research. there is no quantitative measurement, no attempt to David Sackett was the first director of the Department discover what would have happened if the patients had of Clinical Epidemiology and Biostatistics at the had no treatment, and ever possibility of bias affecting Medical School established in 1967. He claimed that the assessement of the result. It could be described as the clinicians should be trained to develop skills needed simplest (worst) type of observational evidence3. to ask epidemiological questions relevant to solve practical clinical problems. Since then, debates At that time a dilemma emerged: What are the rules about Sackett's proposal have target the meaning of evidence that should be adopted as the basis for and relevance of epidemiological knowledge in the clinical management of patients? Should only RCT clinical practice, as well as the uncertainty of medical - validated evidence be used to prevent or minimize judgments based on medical authority1. the use of therapeutic resources innocuous or harmful to patients? Or should clinicians experiences David Sackett were influenced by Alvan Feinstein’s also be admitted as a basis for maximizing the ideas questioning the authority of medical knowledge potential patients health benefits8? and the individual judgment arising from clinical experience. Feinstein, Professor of the Yale University Yet in 1976, at Copenhagen, Hendrik Wulff had School of Medicine, one of the founders of Clinical detailed the logical and probabilistic aspects involved Epidemiology, proposed a method for applying in the application of RCT outcomes in clinical practice9. scientific criteria to clinical judgments and solving the He drew attention to the difference between problem of uncertainty in medical practice, anticipating therapeutic efficacy as measured by the statistical the proposals for Evidence-Based Medicine (EBM) that likelihood obtained from RCT and clinical effectiveness would later be launched by Sackett2. as measured by the subjective likelihood of the physician's belief in the cure of a particular patient, The other side of Atlantic, in the 1970’s, Archibald calculated by applying the Bayes theorem. Even Cochrane3,4 advocated the use of randomized patients with the same disease differ in a number of controlled trials (RCT) to ensure effectiveness and ways, so that it is not always rationally certain that the efficiency in prevention and treatment procedures physician will base his belief (subjective probability) undertaken by the National Health System (NHS) of on the overall experience of a group of patients the United Kingdom, disseminating and systematizing (statistical probability). In addition, the physician the pioneering studies of medical statistics conducted should assess to what extent it is appropriate to apply by Austin Bradford Hill from 19375,7. group experience to the individual10. According to Cochrane, clinical opinions were the worst In the 1980s, clinical epidemiology spread type of evidence for scientifically test a hypothesis: internationally in medical education curricula, despite the difficulties faced due to the required Two of the most striking changes in word usage in mathematical and statistical knowledge and skills11. the last twenty years are the upgrading of “opinion” The initial stimulus for this diffusion came from in comparison with other types of evidence, and the the Rockefeller Foundation, which in 1978 funded downgrading of the word “experiment”. (...) the establishment of the International Clinical J. Évid-Based Healthc., Salvador, 2019 December;1(2):125-130 Doi: 10.17267/2675-021Xevidence.v1i2.2485 | ISSN: 2675-021X 126 Epidemiology Network (INCLEN) to train medical (…) (EBM), the emerging clinical discipline that brings the professors in clinical epidemiology methods to best evidence from clinical and health care research to the promote curriculum changes and health policies in bedside, to the surgery or clinic, and Co the community. “third countries world”12. The practice of EBM is a process of life-long, problem- based learning in which caring for our own patients creates die need for evidence about diagnosis, prognosis, In 1989, Iain Chalmers published the first systematic therapy, and other clinical and health care issues. In the RCT review involving an international collaboration EBM, process, we 1) convert these information needs into that gave rise to the Cochrane Collaborations and answerable questions; 2) track down, with maximum Oxford University's Cochrane Center in 1992, with efficiency, the best evidence with which to answer them NHS resources, directed by Muir Gray. They invited (whether from the clinical examination, the diagnostic David Sackett to move to the University of Oxford, laboratory, the published literature, or other sources);
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