The Case for EBM
By John J. Stienstra, DPM, FACFAS
The medical community is increasingly being asked to substantiate claims and
treatment methodologies by both payers and receivers of care. This pressure has
driven changes in medical and surgical practice. The answers are out there; they
can be found in evidence-based medicine.
This kind of evidence is not easy to acquire. It demands careful and
rigorous randomization, control of variables and bias, and then careful
statistical evaluation. Well-designed, well-performed trials lead to truthful
What does this mean to the frontline clinician? It means that one must always
question the assumptions of the community standard. It also means that
clinicians are tasked with critically appraising the literature and honestly
answering questions that their patients ask regarding their care.
What Should We Do?
- Become familiar with the terminology of EBM hierarchy of study designs.
- Level 1 consists of randomized control trials (called the gold standard for
evidence) and systematic reviews of all randomized control trial data, including
- Level 2 consists of cohort studies and their systematic reviews.
- Level 3 consists of case control studies and their systematic reviews.
- Level 4 consists of case series.
- Level 5 consists of expert opinion without explicit critical appraisal, or
based on physiology, bench research, or first principles.
- In an effort to increase EBM awareness and promote EBM culture, ACFAS has
taken significant steps to grow EBM in our discipline.
- The Journal of Foot and Ankle Surgery categorizes submissions as to
their place in this hierarchy of evidence.
- Research presentations at the College’s Annual Scientific Conference are
categorized in this hierarchy.
- Read the EBM literature.
- Read medical and surgical literature critically, using EBM
- Ask your residents and medical students to find evidence on the clinical
questions you face in daily practice.
- Take an EBM course and begin using the tools for improving patient care in
- Participate in research.
Foot and ankle surgeons need to be become practitioners of EBM. The benefits
include making you aware of new innovations that may be of value when treating
patients and helping you critically appraise and evaluate interventions that you
are already using. EBM is a paradigm shift in medicine, but it is a necessary
tool that will improve patient care and care efficiency.