Evidence-based medicine as the compass, not the cookbook

Its principles are now being put to the ultimate test as they form the critical backbone of the national RESET strategy and its flagship base MHIT plan.

From Dr Rajeentheran Suntheralingam, Dr Musa Nordin, Dr Ahmad Faizal Perdaus, and Dr Sng Kim Hock

In an era of information overload and rising healthcare costs, a term echoes through hospital corridors, policy debates and clinical guidelines: evidence-based medicine (EBM). Yet, it is often misunderstood – dismissed by some as a rigid, soulless protocol, or embraced by others as an infallible scientific scripture. The truth, as with most profound concepts, lies in the nuanced middle.

EBM is neither a cookbook nor a crystal ball; it is the fundamental navigational compass for modern healthcare, guiding decisions from the bedside to the boardroom.

Its principles are now being put to the ultimate test as they form the critical backbone of the national RESET strategy and its flagship base MHIT plan, particularly in the high-stakes arena of determining justified outpatient treatment.

At its core, EBM is the conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients.

Pioneered in the 1990s, it emerged as a corrective to a tradition of medicine based on anecdotes, unsystematic experiences and outdated theories. The classic EBM model rests on a three-legged stool:

1. The best available clinical evidence (from systematic research)
2. The clinician’s expertise and judgment
3. The patient’s values, preferences and unique circumstances

To mistake EBM for “cookbook medicine” is to miss the forest for the trees. A cookbook implies a fixed recipe for a standardised ingredient.

EBM, in contrast, provides the proven culinary principles – the understanding of how heat, acid and salt interact – which the skilled chef (the clinician) then applies to the specific ingredients at hand (the patient). A recipe demands blind adherence; a principle demands intelligent application.

For instance, while evidence shows that most uncomplicated dengue cases can be managed outpatient, EBM further equips the doctor with the know-how to identify the specific “red flags” – severe abdominal pain, persistent vomiting, rapid plasma leakage – which signal that the person before them requires admission.

EBM and reproducibility in practice

The non-negotiable cornerstone of EBM is reproducibility in practice.

Scientific evidence is not a collection of interesting one-off stories; it is a body of knowledge that must yield consistent, reliable outcomes when applied under the same conditions.

If a treatment claimed to be “evidence-based” works only in one prestigious hospital but fails everywhere else, it isn’t the practice that’s flawed – it’s the evidence claim. Reproducibility ensures that a diabetic in Alor Setar receives care as effectively rooted in science as one in Kuala Lumpur, creating a standard of care that is both credible and equitable.

Malaysia’s RESET strategy and base MHIT plan

Faced with soaring medical inflation and an unsustainable claims culture, the RESET strategy is an attempt to right the ship by introducing standardisation, transparency, and financial sustainability. The base MHIT plan is its operational engine, a standardised insurance product designed to provide a baseline of coverage.

Critics have argued that the plan’s cost-sharing measures (deductibles and copayments) simply shift burdens onto patients. However, viewed through an EBM lens, a primary purpose of these measures is to align financial incentives with evidence-based care pathways.

The controversial design that categorises conditions like uncomplicated dengue, mild pneumonia/bronchopneumonia, bronchitis and influenza A and B, as primarily outpatient treatments is not a cost-cutting gimmick; it is a direct application of EBM on a systemic scale.

The evidence is clear and reproducible

For dengue: WHO guidelines and local data show 70-80% of cases are uncomplicated and, with proper monitoring, can be safely and effectively managed at home, avoiding unnecessary hospital exposure and cost.

For pneumonia: Clinical tools like the CURB-65 score reliably identify low-risk patients for whom outpatient oral antibiotic therapy is the standard of care globally and in Malaysia’s own clinical practice guidelines.

The base MHIT plan aims to discourage the “buffet table syndrome” – where the mere presence of insurance leads to medically unnecessary hospital admissions for conditions that are, by all evidence, suitable for outpatient management.

It is an attempt to nudge both providers and patients towards an evidence-backed site of care which is effective, safe and efficient. In doing so, it protects the financial viability of the insurance pool (ensuring that funds are available for truly catastrophic illness) and the physical capacity of hospitals.

EBM in the real world

Implementation is where the rubber meets the road. A doctor in a private hospital at the emergency department at midnight, faced with an insured patient with mild fever and a positive early dengue test, is in the EBM crucible. The evidence says that outpatient monitoring is safe. The patient, conditioned by a legacy of full-cover insurance, may insist on admission “to be safe”.

The clinician’s expertise must now fuse the evidence with human psychology, communication skills, and a duty of care.

This is where the clinician’s judgment becomes paramount. They must explain the red flags, provide a safety net plan and educate. The base MHIT plan supports this by making the outpatient pathway the financially sensible default, backing the doctor’s evidence-based recommendation. Policy can create the framework, but trustful doctor-patient partnerships deliver the care.

EBM is not static. The “current best evidence” evolves. The RESET strategy and base MHIT must, therefore, have built-in agility.

As new treatments, diagnostics or epidemiological patterns emerge, the guidelines underpinning the plan’s coverage must be reviewed and revised – creating a living, breathing system of clinical committees and data feedback loops, ensuring that the system continuously adapts.

A pillar for a sustainable future

To understand EBM is to understand that it is a discipline of wisdom and experience, not just knowledge. It provides the map, but clinicians and patients walk the path together.

In the context of Malaysia’s ambitious healthcare reforms, EBM is the keystone that holds the arch together. It justifies the clinical protocols that underpin the base MHIT’s design, ensures that treatments are reproducibly effective nationwide, and ultimately justifies to the public why some care is best delivered outside a hospital ward.

The success of the RESET strategy will hinge on its faithful yet intelligent application of EBM. It must avoid being seen as a blunt tool for cost-cutting and instead position itself as a champion of delivering the right care, in the right place, at the right time. - FMT

Dr Rajeentheran Suntheralingam, a urologist, Dr Musa Nordin, a paediatrician, and Dr Ahmad Faizal Perdaus, a respirologist, practise at Damansara Specialist Hospital. Dr Sng Kim Hock is a neurologist at Pantai Medical Centre.

The views expressed are those of the writers and do not necessarily reflect those of MMKtT.