Imagine you are a railroad engineer and you know the train must travel over some buckled and irregular track. You want to avoid a derailment, so you ask other engineers what they might do. You then devise a plan to add extra ballast to weigh down every other car in the train, because a couple of "old timers" told you they had a good experience keeping a train on the tracks with this method a few years ago. Risky, but based on the "expert" advice, you give it a try. The plan costs extra money for fuel and labor, time is lost in the preparations, and—the train derails anyway. Where are the ROEMs (Railroad-Oriented Evidence that Matters) when you need them?

I am sure you have seen through this thinly disguised analogy by now. Evidence that matters to our hypothetical railroad is identical to evidence that matters to our patients—it should help to guide our decision-making toward safer, less costly outcomes—the ones the "owners" (ie, the railroad executives or the patients) really desire.

Evidence-based decision-making has evolved from a catch phrase of jargon into a necessary component for excellence in clinical education and in patient care. With the logarithmic increase in medical knowledge, we must have an approach to gleaning the answers to clinical questions that sorts the "wheat" from the "chaff" and allows for cost-effective diagnosis, treatment, and counseling of our patients.

To use a current example from medicine—one of your patients in your practice has a history of nonembolic stroke, and he continues to have transient ischemic attacks (TIAs) despite using low-dose aspirin for prophylaxis. What should you do about this patient—increase the aspirin dose, add another platelet antagonist, anticoagulate the patient, or make no changes in therapy?

Searching the evidence-based literature makes answering this question easy. Using the Cochrane Library,¹ the Agency for Health Research and Quality,² or BMJ Clinical Evidence,³ we find that "for patients with non-cardioembolic ischemic stroke or TIA, antiplatelet agents rather than oral anticoagulation are recommended to reduce the risk of recurrent stroke and other cardiovascular events (Class I, Level of Evidence A)."⁴

In addition, "Compared with aspirin alone, both the combination of aspirin and extended-release dipyridamole and clopidogrel are safe. The combination of aspirin and extended-release dipyridamole is suggested over aspirin alone (Class IIb, Level of Evidence A)."⁴

As the Editor-in-Chief of this journal for the past 3 years, I have encouraged our authors—via the peer-review process—to pay closer attention to the quality of the evidence-based recommendations they are using. We need to be moving beyond the era of placing blind trust in expert advice as the basis for our clinical decisionmaking. By now we have all become familiar with the taxonomy of the Oxford Centre for Evidence-Based Medicine (www.cebm.net/levels_of_evidence.asp) or the Strength of Recommendation Taxonomy (SORT) system (www.stfm.org/fmhub/fm2004/February/Barry141.pdf). These methods of rating the evidence tell us how much credence to place in the recommendation given.

As an over-simplified summary, we should be choosing to base our medical advice on evidence of Level I or Level A rigor. I strongly encourage anyone who wishes to contribute an article to this journal to go the extra mile and search for evidence-based medical conclusions and recommendations; this will enhance your contribution to the medical literature and increase the likelihood that your article will be accepted for publication in Resident & Staff Physician.

References

1. The Cochrane Library. Available at www.cochrane.org/index.htm.
2. Agency for Health Research and Quality. Available at www.ahrq.gov/.
3. BMJ Clinical Evidence. Available at www.clinicalevidence.com/.
4. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council on Stroke: cosponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of these guidelines. Stroke. 2006;37:577-617.