I understand this question. But also, we must remember that EBM must be only an advice and not the guide of the total decision of a therapeutic approach. This is the Art medical field, I think.

Extrapolations of study content and confusing association with causation are common pitfalls in the application of the evidence-based medicine process. Personal bias can be another barrier in the adoption of evidence-based medicine. It can be difficult to modify personal bias despite the evidence; keeping up with the medical literature in a busy practice can be daunting.

The hopes, fears, and mixed record of EBM are rooted in the traditional professional perspective of the clinician as sole decision-maker. Multifaceted implementation strategies that take the collaborative nature of medical work into consideration promise more effective changes in clinical practice.

Following the conclusion that guidelines are scientifically superior but their reception is weak, EBM supporters have shifted the focus of the field from the creation of practice guidelines to the science of implementing them. Several meta-reviews of the introduction of practice guidelines have concluded that the passive educational strategies commonly used have little effect in changing behavior. More promising avenues involve reliance on opinion leaders, methods of providing concurrent feedback, and academic detailing. These strategies work occasionally for some interventions and some groups of practitioners.

The success of the current EBM paradigm has been constrained by its orientation toward a traditional image of the autonomous medical professional decision-maker. The construction and implementation of clinical practice guidelines tend to remain the exclusive purview of leading experts and thereby regularly fail to take into account available resources and opinions of allied professionals, support staff, and patients who will be directly affected by the guidelines. Adherence to guidelines is also seen as a matter of individual choice. In keeping with traditional conceptions of professional autonomy, few mechanisms have been put in place to encourage the use of EBM or to discourage individual deviation from accepted guidelines. The individualistic, voluntary, and exclusive character of EBM as it is largely implemented undermines its overall effectiveness as a tool for improving care.

I think the answer was part of your question. You wrote  "......The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research...." . So your expertise is the first defense line as mentioned by Jair. The second line is the critical appraisal you  are going to do before accepting the evidence or the paper.

I think what endanger the EBM is the traditional medical/ health science schools, particularly in developing countries, where teaching and practice relied very much on text books and teacher experience only.

The introduction of EBM has been an important paradigm shift, however, it's principal weakness is that the design of many important trials simply do not reflect everyday clinical practice. This credibility gap is an unmet need.

Even though EBM is an essential element in clinical practice, its not always practice this in most of the third world countries due to poor resource settings. In Sri  Lanka most physician even give most potent antibiotics on best guess!!

EBM at some point of time created a situation where the teacher's believing in traditional practice and thier experience got bullied by the text....somewhere down the line...it does get harsh on thier beliefs and hurts the ego.

EBM implementation in the clinical setting alerts a clinician that whether the current practice she or he applies on the patient's problem is just a knee-jerk response or something taught by a senior but having weak evidence. And then with this insight, the clinician shall be able to do a literature search whether be it secondary or primary database. Later on, with adequate critical appraisal skill and self-expertise experience, the clinician can determine the level of Evidence. After several rounds of practice, the clinician can improve the practice and affect colleagues through the practice of EBM. EBM never fails in the point-of-care and daily practice.

Maybe the assumption that the application of evidence-based medicine is entirely dependent on 'conscientious and explicit decision-making' is false. Recently research has shown that clinicians behavior is often driven by more implicit or unconscious processes such as habits (Presseau, et al., 2014; Annals of Beh Med). In other words if clinicians perform a certain evidence-based activity for many years, the countless repetitions of that behavior might lead them to form a habit. If now a new evidence-based practice is introduced clinicians might have problems changing their old habits, just like some of us find it hard to change their eating habits for example. Maybe we need to focus on helping clinicians break their old habits and help them create more effective ones, rather than just providing them with rational arguments of why they should practice a certain evidence-based practice. I am currently working on developing theory-based behavior change interventions to help clinicians change their habits. I hope that in the future my work will help increasing the uptake of evidence-based practices and help decreasing the use of outdated and potentially harmful practices.

The problem facing clinicians is whether to rely on ' evidence based medicine ' or 'experience based medicine ' . Clinicians would prefer definite guidelines for diagnosis & management of diseases & therefore those who design them , should consider all aspects before framing it . For example , diagnosis of diseases would be based on diagnostic tests , but if there are not available or very expensive , patients have to be treated on the basis of experience & there could be errors in management . The clinician has a tough choice to make the correct decision . Evidence based medicine has made a significant contribution to improve diagnosis & management , but clinicians have definite problem , if facilities to follow them are not available . The concept of empiric therapy has therefore , emerged as an alternative , if evidence is not available due to various reasons . Therefore , guidelines should consider all aspects to guide clinicians to do the best for the patients .

Remembering all patients are individuals, it is important to note there are essentially three parts to Evidence Based Practice (EBP) best research evidence, the provider's clinical expertise, and patient's values and circumstances (Engebretson, Mahoney, & Carlson, 2008). This is important to remember due to there is no one-answer for all patients. In order to provide care that is appropriate, the patient must understand and agree with the care, the care must be researched and the evidence suitable for the individual patient, as well as being appropriate for the specific situation.

Very recently, CDCP warned that the world is staring at a post-antibiotic era when common infections will no longer have a cure. Not only Anti-biotics; there are many synthetic drugs for which the patients are becoming resistant.

The other facet of coin is Life Style Disorders. Drastic changes in life style, increased industrialization, and pollution lead to the manifestation of life style diseases for which the modern system of medicine have no answer.

Considering these limitations; the suffering population and scientists are searching for safe and suitable options from traditional systems of medicines. Ayurveda, the most trusted ancient medical science of India can provide answers to many situations of suffering population. 

Looking into all these; i prefer to say CONVENTIONAL MEDICINE is falling and TRADITIONAL SYSTEMS are raising.

There is a case for 'real' EBM - http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=84e15604-08bf-4317-8323-cf46b485b7c0&ID=14

Although the EBM is a logical and correct way in order to come to a decision about treatment of patients, it has some failures in practice:

1.       To act upon EBM a practitioner needs a powerful and enriched source of international medical data base that is not accessible in many area of the world.

2.       Practitioners (especially general practitioners and Internists) need to read and study a huge pile of papers nearly every day that seems impossible especially in the near future.

3.       The changes and shifts of medical behavior in some fields are that much dramatic that may completely impair the patient-practitioner positive relation and even damage patients trust on practitioners (especially when all of these changes are about controlling the diseases not curing of them).

4.       The high levels of EBM like systematic reviews do not and in some categories will not have enough documents to help practitioners in near future.

5.       In some categories like CAM and holistic medicine, EBM needs some changes and correction in the methodologies of its basic trials that need lots of time and money.

So, as I told before, although EBM is a real need and rational behavior in medical practice, it needs to come over its practical problems.   

I think unless and until one has to take up teaching as a profession...one just gets time to look into the conclusion or zest of the discussion .It is very difficult in practice to carry both together.

Although EBM is a way to go, treating all the patients in a similar way is wrong. Every patient is different and what is good for one may not be for the other. 

I think EBM not failing. But unfortunately not enough effective as we expected and this is not failing, this is a "good experience for future". May be achieving better results if we pay more attention to "Knowledge Translation" issue   

Placebo controlled double blind studies are conducted under artificial conditions, otherwise nobody knows the impact of circumstances to the real life effect in an observational study. So I want to cite Massimo Pigliucci, philosopher and biologist: "As it turns out, every scientific theory ever proposed in the past has eventually been proven wrong and has given way to new theories. The emphasis of EBM on skepticism and uncertainty-we will never be sure of the magnitude of the effects of our treatments or the power of our diagnostic tests- is central to the approach and agrees with the philosophical view, that scientific knowledge is never complete and ultimately fallible." There is no a-priori probability equatable with zero. Science should not be selected by someone's wishes. Science is always based on one's total evidence, which includes both evidence and science based medicine. So think of the 18th century, people suffering from scorbut, experience showed that they could be protected and healed be oranges and lemons, long before we know something about vitamins and biochemistry. EBM would have shown us high efficacy, although natural science had no idea why.