This is a defense mechanism against the next logical inference: “if the EBM zealot thinks the AHA is acting stupidly, he must think I’m both stupid and a sucker.” No one likes being told he or she is an automaton. So EBM zealots are demeaned as pushy and arrogant, instead of well-meaning, ethical, curious adult learners who focus on patient-centered outcomes. While some of us may exhibit some or even all of these qualities, the former should not disqualify the latter.

Stage 3: Bargaining

“This treatment can’t be studied,” they might say, which is true in some cases. That is not my focus here. I’m more interested in the low-hanging fruit. If a medical intervention can be studied, and it has been (such as epinephrine in pre-hospital ACLS), why do so many recoil against the data and the conclusions which naturally follow? More bargaining ensues. “Maybe they needed a bigger sample size.” “If I look at the data just right, maybe I can identify subpopulations for whom the intervention works or confounders that discredit this study.” While true, it is unlikely that investigators are under reporting positive effects of medical interventions. If the “target” exhibits this kind of careful data analysis toward a research paper whose data discredit a historical best-practice, an inflection point may have been reached.

Such critical thinking implies genuine inquiry and data-driven curiosity possibly leading to the adopting of the anti-dogmatic pro-data approach that the EBM zealot hopes to spread.

Stage 4: Depression

“Was everything I was taught all for nothing?” “Are we no better than the charlatans from days of yore?” “Were my teachers lying or incompetent?” “Are the boards filled with drivel?” “Are all of my colleagues a bunch of suckers? Am I one?” There can be an understandable sense of hopelessness and bemusement as the new EBM convert discovers more examples of futile treatments in our practice. Further, the convert may find that pointing out these unpleasant truths is frequently met with opposition and even alienation. Indeed, depression may be appropriate and can signify the point-of-no-return for the “target” turned “convert” or perhaps “zealot.”

Stage 5: Acceptance

The target stops fighting the urge to cling to dogmatic teachings that have been discredited in the primary research literature. Now a convert, this person seeks data to support interventions and asks important questions about the quality and applicability of the literature. The target may actually become an EBM zealot, participate in well-designed, adequately powered research, and approach official guidelines and newly minted research papers with a wary eye. Noticing that few physicians engage in this practice can – fortunately or unfortunately – lead the new EBM zealot back to Anger (Stage 2). However, this may be a “good” Anger, if sublimated into talking to other physicians and students about rational medicine and patient-centered outcomes. On the other hand, the target may enter into the Acceptance stage resigned that “this is just the way things are” and “there is nothing I can do to change it.”