Rosner Anthony L
International College of Applied Kinesiology, USA.
J Bodyw Mov Ther. 2012 Jan;16(1):42-9. doi: 10.1016/j.jbmt.2011.05.003. Epub 2011 Jun 24.
Evidence-based medicine (EBM) is beset with numerous problems. In addition to the fact that varied audiences have each customarily sought differing types of evidence, EBM traditionally incorporated a hierarchy of clinical research designs, placing systematic reviews and meta-analyses at the pinnacle. Yet the canonical pyramid of EBM excludes numerous sources of research information, such as basic research, epidemiology, and health services research. Models of EBM commonly used by third party payers have ignored clinical judgment and patient values and expectations, which together form a tripartite and more realistic guideline to effective clinical care. Added to this is the problem in which enhanced placebo treatments in experimentation may obscure verum effects seen commonly in practice. Compounding the issue is that poor systematic reviews which comprise a significant portion of EBM are prone to subjective bias in their inclusion criteria and methodological scoring, shown to skew outcomes. Finally, the blinding concept of randomized controlled trials is particularly problematic in applications of physical medicine. Examples from the research literature in physical medicine highlight conclusions which are open to debate. More progressive components of EBM are recommended, together with greater recognition of the varying audiences employing EBM.
循证医学（EBM）面临着诸多问题。除了不同受众通常各自寻求不同类型的证据这一事实外，循证医学传统上纳入了临床研究设计的等级体系，将系统评价和荟萃分析置于顶端。然而，循证医学的经典金字塔排除了众多研究信息来源，如基础研究、流行病学和卫生服务研究。第三方支付者常用的循证医学模式忽略了临床判断以及患者的价值观和期望，而这些共同构成了有效临床护理的三方且更现实的指导原则。此外，实验中强化安慰剂治疗可能会掩盖实践中常见的真实效果这一问题也存在。使问题更加复杂的是，构成循证医学很大一部分的质量不佳的系统评价在纳入标准和方法评分方面容易出现主观偏差，这已表明会扭曲结果。最后，随机对照试验的盲法概念在物理医学应用中尤其成问题。物理医学研究文献中的例子突出了一些有待商榷的结论。建议采用循证医学中更先进的组成部分，并更多地认识到使用循证医学的不同受众。
