Whose evidence is it based on?

One of the arguments that continually came up in the IDSA Lyme guidelines hearing was that of using evidence-based medicine (EBM) in the treatment of Lyme disease. Part of EBM requires the healthcare professional to be apprised of the most authoritative studies for the treatment of a particular condition, in order to give the best patient care. This is laudable in all of healthcare, including Lyme disease. But it is only part of what EBM is. According to the Centre for Evidence-Based Medicine, EBM is a fusion of:

• best research evidence, especially that derived from relevant patient studies
• clinical expertise, emphasizing the healthcare professional's experience with the disease and with the patient
• patient values, which may include variables such as personal preference, lifestyle needs, religious convictions, literacy, compliance, and cost

Dr. David L. Sacket, one of the fathers of EBM, and his associates had this to say about the practice of EBM:

The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.... Evidence based medicine is not "cookbook" medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients' choice, it cannot result in slavish, cookbook approaches to individual patient care. External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all...

When it comes to an emerging diseases such as tick-borne illness, true evidence-based medicine would be welcome, but it should be noted that the current few studies using too few patients with only a few treatment options might not pertain to the many ways in which a patient may manifest the disease or respond to treatment. According to EBM, in such cases, the clinician's judgment and the patient's values should be allowed to prevail.

Sacket, D.L., Rosenberg, W.M.C., Gray, J.A.M., Haynes, R.B., and Richardson, W.S. (1996). Evidence based medicine: what it is and what it isn't, British Medical Journal 312, 71-72. Retrieved September 7, 2009 from http://www.bmj.com/cgi/content/full/312/7023/71 (free registration required).

See also Dr. Daniel Cameron's testimony at http://idsociety.org/Content.aspx?id=15026 and his article, "Generalizability in two clinical trials of Lyme disease" in the October, 2006 edition of Epidemiologic Perspectives and Innovations.