Evidence-Based Medicine: A Framework for Clinical Practice

Edited by Daniel J. Friedland. Pp. 263. Price, $26.95. Appleton and Lange, 107 Elm St., P.O. Box 120041, Stamford, CT 06912-0041, 1998. Phone: 800-423-1359.

Evidence-Based Medicine: A Framework for Clinical Practice is meant to serve as an introduction to the theory and practice of evidence-based medicine (EBM). Its 10 chapters present an overview of the topic, working from the central principle of answering clinically relevant practice-based questions. The book is organized in a different way than several previously published texts on the topic of EBM. “Traditional” EBM texts split their explanation of the topic into separate sections on assessing the validity of articles on treatment, diagnosis, prognosis and clinical reviews. This book instead starts with four chapters on the theory and application of clinical decision analysis—in other words, the subject of explaining how a clinician rationally decides if he or she ought to order a test or use a potential treatment.

The book then moves on to three chapters devoted to locating evidence-based information, either in MEDLINE, journals or on the Internet. Finally, the last two chapters deal with assessing the relevance and validity of the information found in these sources.

The novel EBM framework presented by the authors is simple and elegant. Because the information is presented in a different way than is usual for EBM texts, there are no separate chapters for locating, assessing the validity or applying the information from articles on diagnosis, treatment, prognosis or clinical reviews. In order to pull off this sort of intellectual integration, the authors have to apply some mathematical reasoning from epidemiologic theory. This makes for more difficult chapters at the end of the book. For the motivated reader, the reward is a deeper understanding of the principles of clinical epidemiology and how they apply to the research that drives the decisions that he or she makes in practice each day.

In summary, this book has some features that other books on EBM do not. It has more in-depth treatment of Internet information resources than previous EBM books. It even has a companion Web site. Additionally, the book presents a more rigorous theoretic approach to EBM than other texts. Some may consider this theoretic approach a step backward because most EBM proponents have spent their careers trying to make the arcane theories of clinical epidemiology simple and usable for the masses of practicing clinicians. On the other hand, the integrated framework of the book does explicate the underlying principles of EBM better than most texts. It also should be noted that all but one of the authors are in internal medicine, so the examples used are almost exclusively from this field.

In the end, though the authors intended the book to be an introduction to the field of EBM, I believe that Evidence-Based Medicine: A Framework for Clinical Practice will be most useful for those already initiated into the ways of EBM. The book can help them deepen their understanding and fully integrate EBM into their everyday practice. For those interested in an introduction to EBM, a better starting point is probably Evidence-Based Practice in Primary Care by Chris Silagy and Andrew Haines (BMJ Books, London, 1998, 188 pages, $43.00), although it is a bit expensive and not as comprehensive.

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