Research Methods & Ethics · 1992
Evidence-based medicine: a new approach to teaching the practice of medicine
Evidence-Based Medicine Working Group
In the early 1990s, most clinical teaching still organized itself around the authority of the senior clinician. Attending physicians taught by example and distilled experience; pathophysiologic reasoning determined what treatment should work; and the notion that a busy practitioner should read and appraise primary literature was largely aspirational. At McMaster University in Hamilton, Ontario, Gordon Guyatt had been developing an alternative philosophy within his residency training program, one that treated published research as a primary tool of clinical reasoning rather than an occasional supplement to it.
Guyatt coined the phrase evidence-based medicine in a 1991 ACP Journal Club editorial, but the concept reached a wider audience through the 1992 paper in JAMA, authored by the Evidence-Based Medicine Working Group, a collaborative that included faculty and trainees from McMaster and other institutions. The paper's argument was direct: unsystematic clinical experience and pathophysiologic reasoning were insufficient guides to patient care; physicians needed to locate, appraise, and apply published research in a systematic and explicit way. It described a framework, not just a slogan.
JAMA published the piece as a Special Communication, and it appeared alongside the first installments of the Users' Guides to the Medical Literature, a companion series that ran through the 1990s. Those guides were practical and specific: they taught physicians how to read a randomized trial, how to interpret confidence intervals, when to trust subgroup analyses, and how to use likelihood ratios at the bedside. The series addressed clinical questions by specialty and study design, giving the framework enough operational detail to actually change how residents read journals.
Medical schools across North America and the United Kingdom began incorporating EBM curricula within a few years. The UK's National Health Service embedded EBM principles into its clinical effectiveness programs. The concept also changed how guidelines were built: rather than expert consensus alone, guideline panels began grading their recommendations by the quality of supporting evidence, a practice now standard in most specialty societies and international health agencies.
Criticism of EBM has been persistent and occasionally sharp. Detractors argued that the framework devalued clinical judgment, that it worked poorly for patients who did not resemble trial populations, and that industry could manipulate the evidence base to favor commercially favorable conclusions. Later proponents, including Guyatt himself, refined the original framework to explicitly incorporate patient values and clinical context alongside research evidence, acknowledging that applying population-level data to individual patients required interpretation, not just retrieval.
Key People
- Gordon Guyatt — Coined the term and led the EBM Working Group at McMaster University
- Evidence-Based Medicine Working Group — Collaborative authoring group that published the 1992 JAMA framework
- David Sackett — McMaster internist and clinical epidemiologist who shaped EBM's foundational methods
- Brian Haynes — McMaster epidemiologist and co-editor of the Users' Guides series
JAMA 1992;268(17):2420-2425
Related landmarks
- 1993 · Founding of the Cochrane Collaboration (Research Methods & Ethics)
- 1996 · CONSORT Statement (Research Methods & Ethics)
- 2005 · Ioannidis, "Why Most Published Research Findings Are False" (Research Methods & Ethics)
- 1976 · Large simple trials and trial overviews (Peto and colleagues) (Research Methods & Ethics)