I very much enjoyed both the humor and the not-so-hidden subtext of the letter on evidence-based medicine, submitted by my friend and colleague Dr Ian Mitchell [BCMJ 2009;51(10):426 [10]].

Along the same lines, would it be possible for one of our esteemed experts to ponder the following question: Is there evidence that evidence-based medicine is beneficial in the scenario of the individual patient, individual physician, office visit context?

We are all aware of patients who do seem to do well with a medication whose benefits have been nullified or disparaged by a team of worthy evaluators. Is this entirely placebo effect, or could it be due to difference within populations? Can large-population studies be extrapolated to the individual?

Of course, we must all be aware of such studies when we are making therapeutic decisions. But sometimes a hunch, based in part on intimate knowledge of the patient, turns out to be the solution to a puzzle. Surely this is one of the advantages to having a GP to call one’s own.

Unfortunately, the EBM proponents (all of us!) have the power to sway bureaucratic decisions. It isn’t right to deny a patient coverage of a medication just because the Therapeutics Initiative says a lesser product is just as good. I can personally attest that pantoprazole works better for me than does rabeprazole, and Therapeutic Initiatives cannot argue that point!
—Lorne Walton, MD
Maple Ridge