I’m sharing my insights into evidence-based medicine (EBM) because, like many, I have long believed it to be the gold standard. However, we have interpreted the evidence with a preference to the mean and ignored the outliers alongside wider biases leading to unintended consequences.

The Dark Side of Randomised Controlled Trials (RCTs) in EBM
Biases in research can arise from poor study design. systematic differences and performance bias, detection and contamination bias, interviewer and chronology bias, misclassification and recall bias with confounding, and confirmation biases.
The most influential is “conflict of interest bias,” where pharmaceutical industries manipulate study designs and selectively publish results, embedding systemic disadvantage. Regulatory bodies often rely on flawed metrics, leading to counterproductive practices.

Despite being trusted for clear, reliable answers, RCTs have their pitfalls. They must meet stringent criteria to be effective, but often:
• Clinical questions are inadequately framed.
• Statistical methods are misapplied.
• Target samples are poorly chosen.
• Randomisation lacks clarity and bias prevention.
• Data collection and analysis are flawed.
• Personal biases influence result interpretation.

Challenges in EBM
Building on the research bias, EBM’s simplicity often fails to capture ecosystem complexity. Narrow participant choices and inadequate demographic datasets analysed through a fixed, medical model mindset exacerbate these problems and assume the mean is more important than understanding the outliers.

Yet, we implement evidence based approaches as if they are the ‘truth’ and where anomalies appear, we reject our own ideas and create self-deceiving cycles.

Interdisciplinary approaches incorporating social sciences, ethics, and patient advocacy offer potential solutions, yet access to research funding and publication is often not easily facilitated and we have created an exclusive scientific community.

The Negative Impacts of EBM
Acknowledging EBM’s potential for harm is distressing. While there are positive outcomes, negative consequences like misinterpreted risks of hormone replacement therapy and the opioid crisis highlight its dangers.

National audits, benchmarking, and performance metrics can perpetuate these issues, reinforcing systemic biases.

Complexity of Patient Require Flexible Solutions
Patients’ real-life circumstances complicate EBM application and where anecdotal experience provides information, this insight is ignored. The focus is on those who seek care, neglecting those who don’t with service evaluations often ignoring the opinions of non-users, reinforcing bias.

Meta-analysis Reinforce Bias
Meta-analyses can amplify statistical effects. Issues like population differences, study quality, and publication bias limit reliability.

Moving Forward
The future of EBM lies in its ability to evolve and incorporate diverse perspectives and methodologies. By integrating qualitative and quantitative data, promoting patient and public involvement, enhancing diversity and inclusion, improving transparency, and fostering interdisciplinary collaboration with understanding when EBM is applied, we can create a more holistic, equitable, and effective healthcare system.

Ultimately, the goal is to ensure that EBM not only advances medical knowledge but also aligns with the real-world needs and experiences of all patients, leading to better health outcomes for everyone.