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 answers.

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?

1. 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 meta-analyses.
   • 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.
2. 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.
3. Read the EBM literature.
4. Read medical and surgical literature critically, using EBM methodology.
5. Ask your residents and medical students to find evidence on the clinical questions you face in daily practice.
6. Take an EBM course and begin using the tools for improving patient care in your practice.
7. 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.