A patient comes to your office with repeated unwanted and intrusive thoughts that prevent her from conducting her daily life activities and that make her anxious. You apply a simple screening and conclude that she may have an obsessive-compulsive disorder. The work-up rules out other less frequent causes of similar manifestations and a more formal diagnostic interview confirms your clinical suspicion [1]. What are the best treatment options you can offer your patient and how successful are they?

Previously in the Journal we have referred to the changes in the paradigm of systematic reviews, the hallmark of evidence-based medicine [2],[3],[4]. These result from the growing importance of publication bias (when studies with favorable results are published more often than those with unfavorable results) and other problems that are appearing in biomedical literature [5],[6],[7],[8],[9],[10],[11]. We can even conclude that the way in which evidence-based medicine is practiced is becoming obsolete. New approaches to evidence are emerging and instead of reading articles and doing critical analysis, a need for readily available reliable summaries is increasingly becoming apparent. The CAT (critically appraised topic) already published this month is a case in point (doi: 10.5867/medwave.2014.05.5964). Aligned with this tendency are current efforts to enhance the quality of clinical practice guidelines. The GRADE group (Grading of Recommendations Assessment, Development and Evaluation Working Group) and the Cochrane Collaboration have been leaders in clinical guidelines and systematic reviews, respectively.

In spite of the limitations mentioned above, we can reasonably conclude that today’s evidence base is far sounder that what was available 20 or 40 years ago. Information technologies and internet have allowed virtually real-time exchange of scientific research advances, making it less likely to hear expressions such as “there is no evidence for.” It is now clear that the dichotomy “there is evidence” / “there is no evidence” does not work. Medicine is much more complex than that. Today we need to know about the benefits and harms of therapy; reliability of existing research; and how we can provide reasonably trustworthy statistics for our patients. This will help in the process of deciding the best course of action for a given patient, in a given setting.

It was not more than 15 years ago that the emphasis was placed on continuing medical education. Now, however, we speak of knowledge translation, a developing science that aims to overcome the gap between what we know and what we practice, as well as overcoming barriers to implement evidence-based practice [12].

Introducing in Medwave a new series called “Evidence-based decision-making” with the purpose of guiding the clinician in the process of making decisions based on the best available evidence. The series will begin with an article authored by professors Ignacio Neumann and Gabriel Rada (doi: 10.5867/medwave.2014.05.5966). Both are members of the GRADE group and the Cochrane Collaboration. Gabriel Rada is also co-director of the Southern American Branch of the Iberoamerican Cochrane Centre. The standing of our authors in the most important international forums on topics such as development of clinical guidelines and evidence reviews for meta-analysis allows us to have the best contributions for our journal. The series will provide essential concepts for the decision-making process in healthcare and will deal with issues such as when it is worthwhile to decide, how to interpret results and what is their reliability, how to translate evidence into clinical decisions and how to take it to the practical context of the patient sitting before us. As with the series “Topics and controversies in biostatistics” that we recently initiated, this series has a beginning but no predetermined ending. The nature of the disciplinary evolution will tell us how to proceed.

Back to our patient with obsessive-compulsive disorder mentioned in the beginning of this editorial. NICE (National Institute for Health and Clinical Excellence) issued a clinical guideline in 2005 [13] with recommendations based on 17 controlled studies that suggests that cognitive behavioral intervention is effective and that there is good evidence for selective serotonin reuptake inhibitors and clomipramine, but associated to psychological therapy to avoid relapse. In the era of GRADE, it would also be necessary to know whether the recommendation is strong (benefits clearly outweigh potential harms), and what is the quality of the evidence. When combining these two components it will be possible to inform the patient so that she may decide on the best possible evidence, bringing into play her own beliefs and her practical possibilities in accordance with her own life project.

Notes

Declaration of potential conflicts of interest
VCB declares that she does not have any conflicting interests with the article’s content.

Acknowledgment
The author thanks Gabriel Rada for helping with some central ideas expressed in this editorial.

Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.