Has evidence-based medicine left quackery behind?

Evidence-based medicine (EBM) is generally considered as the most complete paradigm in the practice of clinical medicine. Its application should preclude all kinds of quackery. Therapeutic reformers of the second half of the twentieth century have convinced the medical community that the double-blind randomized controlled trial (RCT) versus placebo is the gold standard in clinical research to establish evidence of treatment usefulness. Nevertheless, this paradigm ignores the importance of non-specific effects in the healing process and can generate misrepresentations. Additionally, because of methodological limitations, RCTs as they are used in practice can give rise to new forms of quackery by promoting drugs that are not useful for the patients who actually receive them, or are so expensive that their value is open to criticism. This is precisely the case when surrogate outcomes, with questionable clinical significance, are used. These can divert attention from clinically relevant outcomes, such as safety issues that are probably the core of treatment evaluation. The boundaries between quackery and EBM that clinicians are faced with are not so clear-cut. There is a need for doctors to acknowledge their share in quackery and to be continually conscious of the possible pitfalls of their therapeutic practice.