In Search of Evidence

Learning From Other Evidence-Based Practices
public health. Because of its political implications, public health was viewed with
suspicion by both biomedical researchers and clinicians. Therefore, something new had
to be created, to appeal to both groups and provide a viable solution to the problems
of intraphysician variability in behavior and decisions and the cost explosion in health
care at the same time. This is what clinical epidemiology set out to do: although the
research questions of the new discipline were supplied by the clinic, its methods were
solid enough to appeal to basic researchers and applicable to medically defined clinical
populations. In the process, it moved from the periphery to the center of the medical
enterprise. Epidemiology– once considered to be a rather irrelevant discipline by
clinicians–had become clinical epidemiology.
The new discipline was developed at McMaster’s University in Canada, by a team
of clinicians, biostatisticians, engineers, and health economists headed by David
Sackett. Greatly inspired by the work of Feinstein, Sackett successfully launched a
program in which problem-based medical research was translated into a problembased
medical curriculum. The practical questions of medical students were taken as a
starting point. The new approach was embraced and funded by the Rockefeller
Foundation, and successfully exported to other western countries. It didn’t take too
long before clinical epidemiology was institutionalized in a handbook, a journal, and a
network. In 1985, David Sackett, Brian Haynes, Gordon Guyatt and Peter Tugwell
published Clinical Epidemiology: A Basic Science for Clinical Medicine (Sacket, Haynes,
Guyatt, & Tugwell, 1991). Two years later, the Journal of Chronic Diseases was
rechristened the Journal of Clinical Epidemiology, and finally, an INternational CLinical
Epidemiology Network (INCLEN) was established to support clinical epidemiology
worldwide.
Things were taken even a step further by Gordon Guyatt, an early graduate of the
Department of Clinical Epidemiology and Biostatistics at McMaster University. In an
article published in the Journal of the American Medical Association in 1992, he
inaugurated the concept of “evidence- based medicine.” The article was subtitled “A
new approach to teaching the practice of medicine.” It sprang from his need to justify
the training program in the McMaster’s medical school (Evidence-Based Medicine
Working Group, 1992). Physicians of the future needed to be educated differently.
Instead of being knowledge and teacher based, their education needed to be problem
and patient based. To do so, physicians should be able to judge the value and the
applicability of published research. On top of that, they needed to be able to identify
the relevant articles from a plethora of literature. In this respect, Guyatt claimed that
evidence-based medicine represented a paradigm shift for medical practice. Whereas
the old paradigm had valued pathophysiologic first principles, teacher authority,
experience, and unsystematic clinical observation, the new paradigm stressed their