best humanity can do is to triage the application of scarce resources. research can be influenced by biases such as publication bias and conflict of interest in academic publishing. for example, studies with conflicts due to industry funding are more likely to favor their product. it has been argued that contemporary evidence based medicine is an illusion, since evidence based medicine has been corrupted by corporate interests, failed regulation, and commercialisation of academia. systematic reviews methodologies are capable of bias and abuse in respect of (i) choice of inclusion criteria (ii) choice of outcome measures, comparisons and analyses (iii) the subjectivity inevitable in risk of bias assessments, even when codified procedures and criteria are observed. an example of all these problems can be seen in a cochrane review, as analyzed by edmund j. fordham, et al. in their relevant review. a lag exists between when the rct is conducted and when its results are published. a lag exists between when results are published and when they are properly applied. hypocognition (the absence of a simple, consolidated mental framework into which new information can be placed) can hinder the application of ebm. values: while patient values are considered in the original definition of ebm, the importance of values is not commonly emphasized in ebm training, a potential problem under current study. a 2018 study, "why all randomised controlled trials produce biased results", assessed the 10 most cited rcts and argued that trials face a wide range of biases and constraints, from trials only being able to study a small set of questions amenable to randomisation and generally only being able to assess the average treatment effect of a sample, to limitations in extrapolating results to another context, among many others outlined in the study. application of evidence in clinical settings despite the emphasis on evidence-based medicine, unsafe or ineffective medical practices continue to be applied, because of patient demand for tests or treatments, because of failure to access information about the evidence, or because of the rapid pace of change in the scientific evidence. for example, between 2003 and 2017, the evidence shifted on hundreds of medical practices, including whether hormone replacement therapy was safe, whether babies should be given certain vitamins, and whether antidepressant drugs are effective in people with alzheimer's disease. even when the evidence unequivocally shows that a treatment is either not safe or not effective, it may take many years for other treatments to be adopted. there are many factors that contribute to lack of uptake or implementation of evidence-based recommendations. these include lack of awareness at the individual clinician or patient (micro) level, lack of institutional support at the organisation level (meso) level or higher at the policy (macro) level. in other cases, significant change can require a generation of physicians to retire or die and be replaced by physicians who were trained with more recent evidence. physicians may also reject evidence that conflicts with their anecdotal experience or because of cognitive biases – for example, a vivid memory of a rare but shocking outcome (the availability heuristic), such as a patient dying after refusing treatment. they may overtreat to "do something" or to address a patient's emotional needs. they may worry about malpractice charges based on a discrepancy between what the patient expects and what the evidence recommends. they may also overtreat or provide ineffective treatments because the treatment feels biologically plausible. it is the responsibility of those developing clinical guidelines to include an implementation plan to facilitate uptake. the implementation process will involve will include an implementation plan, analysis of the context, identifying barriers and facilitators and designing the strategies to address them. education training in evidence based medicine is offered across the continuum of medical education. the berlin questionnaire and the fresno test are validated instruments for assessing the effectiveness of education in evidence-based medicine. these questionnaires have been used in diverse settings. a campbell systematic review that included 24 trials examined the effectiveness of e-learning in improving evidence-based health care knowledge and practice. it was found that e-learning, compared to no learning, improves evidence-based health care knowledge and skills but not attitudes and behaviour. no difference in outcomes is present when comparing e-learning with face-to-face learning. combining e-learning and face-to-face learning (blended learning) has a positive impact on evidence-based knowledge, skills, attitude and behaviour. as a form of e-learning, some medical school students engage in editing wikipedia to increase their ebm skills, and some students construct ebm materials to develop their skills in communicating medical knowledge.