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Applying Evidence to Patient Care: From Black and White to Shades of Grey

Finlay A. McAlister, MD, FRCPC
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From University of Alberta; Edmonton, Alberta T6G 2R7, Canada.

Grant Support: Dr. McAlister is a Population Health Investigator of the Alberta Heritage Foundation for Medical Research.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Finlay A. McAlister, MD, FRCPC, Department of Medicine, 2E3.24 WMC, University of Alberta Hospital, 8440 112 Street, Edmonton, Alberta T6G 2R7 Canada; e-mail, Finlay.McAlister@ualberta.ca.

Ann Intern Med. 2003;138(11):938-939. doi:10.7326/0003-4819-138-11-200306030-00016
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The interface between evidence and clinical care is complicated: What appears black and white in a trial report may “rapidly become grey in practice” (1). Even when presented with internally valid, well-conducted trials, clinicians frequently face doubts about how we can apply this evidence to our individual patients. The potential problems in extrapolating from trials that are small, are of short duration, rely on surrogate outcomes, or use active controls of uncertain efficacy are well described (25). However, in this editorial, I focus on the dilemma at the heart of Dr. Shlipak's paper in this issue (6): Can we extrapolate from trials conducted in highly selected subsets of patients to a broader population of patients who have the same condition but do not meet the trial eligibility criteria? Indeed, as clinicians we infrequently see the ideal patients who populate clinical trials. Instead, we spend most of our time looking after patients who would have been deemed ineligible to participate in these trials because of age, comorbid conditions, or concomitant medication use.

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