Disclaimer- This is just an argument for the sake of arguing
Dave Sackett’s definition of evidence based medicine (EBM) is “...the conscientious, judicious and explicit use of current best evidence in making decisions about the care of the individual patients”. The current arguments against EBM are that it creates a “paradigm” in which restricts the progress of medicine (Greenhalgh, 2012) and by doing so ultimately reduces the role of the clinicians own rationale when making decisions.
The good evidence based medicine consists of 2 things: first, individual clinician’s expertise and experience and second, the best available evidence from research. (Sackett et al, 1996) From this it’s easy to see that we need both working in harmony in order to get anywhere. From the beginning of medical training, we need EBM as a foundation base for our clinical knowledge and throughout the career this will inevitably change, as it has done so throughout the course of history, and this is partly through EBM. This is something everyone inevitably be going through, whether through learning from epidemiological journals or even anecdotal words from a doctor you’re shadowing, I put forward an argument that both of these are examples of evidence based medicine, albeit the former having an audience now but perhaps the latter having a larger audience in the future once there has been a study.
So why this dichotomy of thought exists between getting external validity through EBM and internal validity through instinct is puzzling. As clinicians we ultimately just want to do what’s best for the patient surely? I agree that there must be some scope for negotiation between guidelines and clinical instinct, simply because there isn’t enough evidence as of yet which can pin down the individual characteristics which make up a human individual (and I contend whether there ever will be) and even the study of medicine alone is not yet complete. That doesn’t however mean we should dismiss the best evidence we have so far and perhaps a solution would be to introduce some mechanism in guidelines which allow some lee way for clinical judgement for those stated reasons. Perhaps there needs to be more research into what makes clinical judgement, the only problem being we are simply limited in what we can do now.
