What evidencebased dermatology is not

Despite its clear definitions, the purpose of evidence-based dermatology (EBD) is often misunderstood in the literature.4 Some of these misinterpretations are shown in Box 2.1. First, EBD does not tell dermatologists what to do.1 Even the best external evidence has limitations in informing the care of individual patients. To use RE Clerk's metaphor, external evidence is just one leg of a three-legged stool, the other two being the clinician's expertise and the patient's values and preferences. Such clinical expertise and discussion of patient factors will always be at the heart of applying evidence during a dermatology consultation. EBM is not a cookbook of recipes to be followed slavishly, but an approach to medicine that is patient-driven from its outset. Patients are the best sources for generating the important clinical questions, answers to which then need to be applied back to such patients.5

Just as ordinary patients are at the heart of framing evidence-based questions, so too are ordinary clinical dermatologists at the heart of the practice of EBD. EBM is not something that only an exclusive club of academics with statistical expertise can understand and practise, but rather it is something that all dermatologists can practise with appropriate training. It is an essential skill that is as basic to being a doctor as the ability to examine and diagnose.

Contrary to popular belief, the prime purpose of EBM is not to cut costs. Like any information source, selective use of evidence can be twisted to support different economic arguments. Thus, the lack of randomised clinical trial (RCT) evidence for the efficacy of methotrexate in psoriasis should not imply that methotrexate should not be used/purchased for patients with severe disease when there is so much other evidence and long-term clinical experience to support its use. But this is not to say that a clinical trial comparing methotrexate and ciclosporin, acitretin or fumarates would not be desirable at some stage.6

EBM should not be viewed as a restriction on clinical freedom, if clinical freedom is defined as the opportunity to do the best for your patients, as opposed to making the same mistakes with increasing confidence. Searching for relevant information for your patients frequently opens up more rather than fewer treatment options.7 The physician-patient partnership is free to choose or discard the various options in whatever way gives the most desirable outcome.

Guidelines are not the same as EBM, although the two are frequently confused.8 Guidelines may or may not be evidence based, but guidelines are just that - guidelines. Many dermatology guidelines now incorporate a grading system that describes the quality of evidence used to make recommendations and their strength.9

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