Do not Fall in the Evidence Based Medicine Trap

Human subtlety...will never devise an invention more beautiful, more simple or more direct than does nature, because in her inventions nothing is lacking, and nothing is superfluous

Leonardo de Vinci

I just bought a book titled "an evidence-based approach to dietary phytochemicals" by Higdon for the Linus Pauling Institute. The title is very attractive Having the term “evidence-based” in the title justified spending $ 57 for the book. The book covers a number of phytochemicals; ones with studies supporting them. I still think the book is worth having. But, I do think using the term “evidence-based” in the title is worth nothing more than its marketing value.

Orthodox medicine uses the term evidence-based medicine (EBM) for a specific purpose, which is not addressed in this book. The book uses this term to emphasize that the claims presented in the book are supported by research. But, this is not EBM as per the people who coined the term. Here, I am not taking orthodox medicine off the hook. I believe that the term EBM is also abused in orthodox medicine literature. You can check my post.

The seeds of evidence based medicine started in 19th century. (Sackett et al. 1996) The movement was an outcry to the quality of research conducted then. The McMaster group that coined the term EBM intended it to be a tool used to make better clinical decisions. Their initial proposition proved to require more time than available to practicing clinicians; therefore, they adjusted it definition to:

the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. (Sackett et al. 1996)

The most practical method to practice EBM in orthodox medicine is to use secondary sources of evidence: The process goes as follows:
someone with available time and resources reviews relevant clinical studies. He/she uses EBM tools presented by McMaster group in JAMA in 1993 (or updated tools) to rate the quality of the study. The level of evidence deciphered from the study is given a rating from one to four (I -IV).
Then, recommendations that are based on this evidence is also rated, but now graded from A to D. Grade A recommendations are usually based on Level Ia and Ib evidence. (The grading does differ slightly between publications, but the general framework stands)
These recommendations are considered secondary resources for evidence. The primary resources are the original research papers.
For example, if a clinical question as should I give vitamin D 5000 IU to a patient with Serum vitamin D of 50ng/mL is raised. And, I find a very poorly conducted study where according to EBM tools rating is level III evidence. If this is the only available evidence, I will use it as it is the best available.  I will then combine this fact with patient condition and values and either prescribe or not prescribe her vitamin D 5000IU.
EBM as intended by those who coined the term is a dynamic process of basing clinical decisions on best available evidence. This evidence can be poor. But, it is assumed the best available.

You must realize that EBM rating tools are designed to assess the quality of research that naturopath see fundamentally wrong. Here, I can quote Landlhr (1913):

No matter how learned a man may be, if he begins a problem in arithmetic with the proposition 2x2=5, he never will arrive at a correct solution if he continue to figure into all eternity. Neither can allopathy solve the problem of disease and cure as long as its fundamental conception of disease is based on error.

At the heart of EBM is a call for better research. We believe in the Law of cure. Therefore,  we believe that well conducted research will prove our theories. But, this will never happen unless orthodox medicine poses the right question.Orthodox clinical research tries to answer questions as :  if I give this medicine will the patient live longer? or will he have less pain? The question that should be answered is: what are the Laws of nature that govern health and disease? Once we know these Laws,we need to  learn how to apply them in clinical situations. We will need good quality studies to discover these Laws and good quality studies to learn how to apply these Laws.
The way I see it, Naturopthic medicine has the right starting point, but is not advancing fast enough mainly due to the lack of resources. While, orthodox medicine has the resources to advance but unfortunately has started with the wrong beginning.

What I am calling for is illustrated by Foster (2003) research. He started with a Law of nature that states that  our cells need the proper nutrition to function well and ended up with the best treatment till date for AIDS. He has the term "EBM" nowhere in his book. It is because he did not use this term he appropriately had to lay the ground for his theory in details supporting it using all available research.

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS., 1996. Evidence based medicine: what it is and what it isn't. BMJ (Clinical Research Ed.), 312(7023), 71-72