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EDITORIAL

What’s In a Word?

MICHAEL W. STEWART, SARAH L. DUNCAN POWERS, STEVEN J. FLIESLER, AND RICHARD K. PARRISH II

O
N DECEMBER 15, 2017, THE WASHINGTON POST confidence in the validity of data. ‘‘Evidence-based medi-
reported that policy analysts at the Centers for cine,’’ as originally described, is ‘‘the conscientious,
Disease Control and Prevention (CDC) were explicit, and judicious use of current best evidence in mak-
given a list of forbidden words by senior CDC officials ing decisions about the care of individual patients.’’8 The
who oversee the budget.1,2 The Post claimed that the hierarchical consensus based on the ‘‘strength of the evi-
United States Department of Health and Human dence’’ was described over 20 years ago (1996) by Sackett8
Services (DHHS) was prohibiting the use of 7 words or (Figure),9-11 and the journal Evidence Based Medicine has
phrases—‘‘vulnerable,’’ ‘‘entitlement,’’ ‘‘diversity,’’ been continuously published since 1995.
‘‘transgender,’’ ‘‘fetus,’’ ‘‘evidence-based,’’ and ‘‘science- These phrases have appeared in the American Journal of
based’’—from appearing in proposed budget documents Ophthalmology many times over the last 20 years.6 On April
for 2019. In some instances, the analysts were given 15, 2005, a PubMed Central search of the terms ‘‘evidence-
alternative phrases to use in budget documents. Instead based medicine’’ and ‘‘ophthalmology’’ yielded 27 citations,
of ‘‘science-based’’ or ‘‘evidence-based,’’ the suggested whereas on December 21, 2017, the same search
phrase has become ‘‘CDC bases its recommendations on yielded 164 results. On December 20, 2017, a Google
science in consideration with community standards and Scholar–based search produced about 334 000 articles
wishes.’’1 and citations. A PubMed Journal Database search for ‘‘ev-
During the ensuing literary firestorm, other journalists idence based medicine’’ identified 47 journals.
claimed that these words have not actually been banned, The American Journal of Ophthalmology vigorously
that general use of the words is still allowed at the CDC supports the underlying principles of evidence-based
outside of the budgetary process, and that the ‘‘forbidden’’ science and medicine. Returning to reporting anecdotal
list merely represents ‘‘guidelines’’ for the analysts to use experiences dependent upon the reputation of the se-
when preparing the Centers’ budget for presentation to nior author and the sheer number of procedures
current authorities.3 performed or patients treated would mark a retreat to
Although the origin and political implications of this the darker and less informed days of medicine.12
ban remain indeterminate, the limitation of ‘‘science- Limiting the use of ‘‘evidence-based medicine,’’ even
based’’ and ‘‘evidence-based’’ phrases is particularly by editing suggestions and word replacements, so as
notable.3,4 This discussion takes place as these widely not to offend government officials or to filter out by
accepted concepts are being increasingly used both by an ideology, raises the specter of an Orwellian shift at
peer-reviewed journals, to judge the value of submis- the DHHS and the legislative branch of government.
sions, and by physicians, to make patient care deci- It is not coincidental that these concepts are discour-
sions.5-8 aged at the point of determination for further funding,
Evidence-based medicine is more than just a definition; leaving the value, strength, and merit of scientific goals
it is a classification system used to qualify the strength of up for ideologically based interpretation and debate.
medical evidence and to instill the appropriate degree of The suggestion that banning, or in any way discour-
aging the use of, the linguistic bedrock of evidentiary
support for new ideas that spawn improvements
of our diagnostic and therapeutic capabilities is para-
Accepted for publication Jan 17, 2018.
From the Department of Ophthalmology, Mayo Clinic, Jacksonville, doxical to the notion of sound science and human prog-
Florida (M.W.S.); American Journal of Ophthalmology, Saint ress.
Augustine, Florida (S.L.D.P.); Department Ophthalmology, Jacobs This globally embraced dictum demands accuracy, valid-
School of Medicine and Biomedical Sciences, University at Buffalo, and
Research Service, VA Western New York Healthcare System, Buffalo, ity, reproducibility, and transparency; and we encourage
New York (S.J.F.); and Bascom Palmer Eye Institute, Miller College of the most rigorous application of commonly used, unambig-
Medicine, University of Miami, Miami, Florida (R.K.P.). uous words and phrases to facilitate frank medical, scienti-
Inquiries to Michael W. Stewart, Department of Ophthalmology, Mayo
Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224; e-mail: stewart. fic, and sociological discussions and to maintain the
michael@mayo.edu positive progress of humankind.

0002-9394/$36.00 © 2018 ELSEVIER INC. ALL RIGHTS RESERVED. 1


https://doi.org/10.1016/j.ajo.2018.01.019
FIGURE. Commonly accepted hierarchy of medical evidence that is obtained from different types of studies.

FUNDING/SUPPORT: NO FUNDING OR GRANT SUPPORT. FINANCIAL DISCLOSURES: MICHAEL W. STEWART: ALLERGAN: ADVI-
sory Board, Institutional Research Support; Alkahest: Consultant; Bayer: Consultant; Regeneron: Advisory Board, Research Support. The following au-
thors have no financial disclosures: Sarah L. Duncan Powers, Steven J. Fliesler, and Richard K. Parrish II. The authors attest that they meet the current
ICMJE criteria for authorship.

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