A ‘reluctant’ critical review: ‘Manual for evidence-based clinical practice (2015)’

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The Users' Guides to the Medical Literature Manual has been a major influence on the teaching and practice of health care globally.


The 3rd edition of the multi-authored Manual was reviewed using the principles outlined in Evidence-based Medicine (EBM) texts. One ‘clinical scenario’ was selected for critical appraisal, as were several chapters; objectivity was enhanced by citing references to support opinions.

Results (summary of the appraisal)

(1) Strengths: Clinical pearls, too numerous to list. Examples: (i) evidence is never enough to drive clinical decision making; (ii) do not rush to adopt new interventions; and (iii) question efficacy data based only on surrogate markers. (2) Weaknesses: The Manual shares shortcomings of textbooks discussed by Straus et al.: (i) references may not be current, important ones may be excluded and citations may be selective; (ii) often, opinion-based; and (iii) delays between revisions. (3) Notable omissions: Little or no discussion of: (i) important segments of the population: those <18 years of age, >65 years of age and those with multimorbidity; (ii) surgical disciplines; (iii) Greenhalgh et al.'s essay on EBM; (iv) alternate views on the hierarchy of evidence; and (vi) critical thinking. (4) Additional issues: (i) Omission of important references on dabigatran (clinical scenario: chapter 13.1); (ii) authors' advice (Chapter 13.3) to ‘bypass the discussion section of published research’; and (iii) the advocacy of pre-appraised sources of evidence and network meta-analysis without warnings about limitations, are critiqued.


The Manual has several clinical pearls but readers should also be aware of shortcomings.

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