Linskey Mark E
Department of Neurological Surgery, University of California, Irvine and UCI Medical Center, Orange, Calif., USA.
Prog Neurol Surg. 2006;19:1-53. doi: 10.1159/000095175.
Evidence-based medicine is a tool of considerable value for medicine and neurosurgery that provides a secure base for clinical practice and practice improvement, but is not without inherent drawbacks, weaknesses and limitations. EBM finds answers to only those questions open to its techniques, and the best available evidence can be a far cry from scientific truth. With the support and backing of governmental agencies, professional medical societies, the AAMC, the ACGME, and the ABMS, EBM is likely here to stay. The fact that: (1) EBM philosophy and critical appraisal techniques have become fully integrated into the training and culture of our younger colleagues, (2) that maintenance of certification will require individuals to demonstrate personal evidence based practice based on tracking and critical analysis of personal practice outcomes as part of the performance-based learning and improvement competency, and (3) that the progressively growing national healthcare expenditures will necessitate increasing basis of reimbursement and funding based on evidence-based effectiveness and guidelines, all point to the likelihood that complete immersion of neurosurgical practice in EBM is inevitable. This article thoroughly explores the history of EBM in medicine in general and in neurosurgery in particular. Emphasis is placed on identifying the legislative and regulatory motive forces at work behind its promulgation and the role that organized medicine has taken to facilitate and foster its acceptance and implementation. An accounting of resources open to neurosurgeons, and a detailed description EBM clinical decision-making methodology is presented. Special emphasis is placed on outlining the methodology as well as the limitations of meta-analyses, randomized clinic trials, and clinical practice parameter guidelines. Commonly perceived objections, as well as substantive problems and limitations of EBM assumptions, tools, and approaches both for individual clinical practice and health policy design and implementation are explored in detail.
循证医学是医学和神经外科领域极具价值的工具，为临床实践和实践改进提供了坚实基础，但也存在固有的缺点、弱点和局限性。循证医学只能回答那些适用于其技术的问题，而现有最佳证据可能与科学真理相差甚远。在政府机构、专业医学协会、美国医学协会（AAMC）、毕业后医学教育认证委员会（ACGME）和美国医学专业委员会（ABMS）的支持下，循证医学可能会持续存在。以下事实表明：（1）循证医学理念和批判性评估技术已完全融入我们年轻同事的培训和文化中；（2）认证维持要求个人基于对个人实践结果的跟踪和批判性分析，展示个人循证实践，这是基于绩效的学习和改进能力的一部分；（3）国家医疗保健支出的不断增加将使基于循证有效性和指南的报销和资金基础不断扩大，所有这些都表明神经外科实践完全融入循证医学是不可避免的。本文全面探讨了循证医学在医学总体领域尤其是神经外科领域的历史。重点在于确定其颁布背后起作用的立法和监管动力，以及有组织的医学为促进和推动其接受与实施所发挥的作用。介绍了神经外科医生可利用的资源，并详细描述了循证医学临床决策方法。特别强调了概述荟萃分析、随机临床试验和临床实践参数指南的方法及其局限性。详细探讨了对循证医学的常见反对意见，以及循证医学假设、工具和方法在个体临床实践以及卫生政策设计与实施方面的实质性问题和局限性。
