Viewpoint: Moving Beyond Evidence-Based Medicine

The evidence-based medicine movement has remained both well known and controversial since its inception. The authors reframe the evidence-based medicine debate by pointing out an underappreciated epistemological deficiency: evidence-based medicine as currently conceptualized cannot accommodate concepts that resist quantitative analysis and therefore cannot logically differentiate human beings from complex machines. The authors use Michael Polanyi's philosophy of tacit knowing (which refers to the taken-for-granted knowledge at the periphery ofattention that allows persons to understand the world and discern meaning in it) as a starting point for rectifying this deficiency and for working towards an improved, person-centered epistemology of medical practice. The authors demonstrate that not only evidence-based medicine but also most traditional theories of medical practice need a concept such as tacit knowing to account for the kinds of knowledge human beings actually use. Polanyi's philosophy of tacit knowing is defined and briefly explained. A medical epistemology that can account for the tacit dimension of human knowledge and recognize physicians and patients as persons requires a revised conception of medical uncertainty and a recognition that clinician–patient interactions are central to medicine. The authors discuss practical implications of tacit knowing for medical practice, education, research, and health care policy and suggest ways for moving beyond evidence-based medicine towards a comprehensive epistemology of medical practice.

[1]  J. Gabbay,et al.  Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care , 2004, BMJ : British Medical Journal.

[2]  P. Welsby,et al.  Reductionism in medicine: some thoughts on medical education from the clinical front line. , 1999, Journal of evaluation in clinical practice.

[3]  C. Melchiorri,et al.  Developments in the evidence-based health care debate - 2004. , 2004, Journal of evaluation in clinical practice.

[4]  Andrea E Crunkhorn.  The Philosophical Limits of Evidence-Based Medicine. Tonelli MR (University of Washington School of Medicine, Seattle, Wash). Acad Med. 1998;73:1234-1240. , 2001 .

[5]  S. French.  Professional Judgment: A Reader in Clinical Decision Making , 1988 .

[6]  Rebecca S. Graves,et al.  Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. , 2002 .

[7]  P. Glasziou.  Evidence based medicine: does it make a difference? , 2005, BMJ : British Medical Journal.

[8]  M. Polanyi.  Personal Knowledge: Towards a post-critical philosophy , 1959 .

[9]  W. Bean.  Personal Knowledge: Towards a Post-Critical Philosophy , 1961 .

[10]  M. Scardamalia,et al.  Surpassing Ourselves: An Inquiry into the Nature and Implications of Expertise , 1993 .

[11]  Gordon H. Guyatt,et al.  Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice; Users' Guides to the Medical Literature: Essentials of Evidence-Based Clinical Practice , 2003, BMJ : British Medical Journal.

[12]  A. Wu,et al.  Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. , 2005, JAMA.

[13]  E. Pellegrino.  The Anatomy of Clinical Judgments , 1979 .

[14]  Alvan Feinstein,et al.  Clinical Judgment Revisited: The Distraction of Quantitative Models , 1994, Annals of Internal Medicine.

[15]  N. Oswald,et al.  Applying research evidence to individuals in primary care: a study using non-rheumatic atrial fibrillation. , 1999, Family practice.

[16]  A. Macintyre,et al.  Toward a theory of medical fallibility. , 1975, The Hastings Center report.

[17]  John M. Byrne,et al.  Evidence-Based Medicine and the Search for a Science of Clinical Care , 2005, Annals of Internal Medicine.

[18]  William R. Hersh,et al.  A categorization and analysis of the criticisms of Evidence-Based Medicine , 2004, Int. J. Medical Informatics.

[19]  R. Haynes,et al.  What kind of evidence is it that Evidence-Based Medicine advocates want health care providers and consumers to pay attention to? , 2002, BMC health services research.

[20]  Tim Thornton,et al.  Tacit knowledge as the unifying factor in evidence based medicine and clinical judgement , 2006, Philosophy, ethics, and humanities in medicine : PEHM.

[21]  Eric S. Holmboe,et al.  Faculty and the Observation of Trainees’ Clinical Skills: Problems and Opportunities , 2004, Academic medicine : journal of the Association of American Medical Colleges.

[22]  M. Tonelli.  The philosophical limits of evidence‐based medicine , 1998, Academic medicine : journal of the Association of American Medical Colleges.

[23]  Goldman Gm.  The tacit dimension of clinical judgment. , 1990 .

[24]  S. Spicker,et al.  Clinical Judgment: A Critical Appraisal , 1979 .

[25]  M. Godwin.  Evidence-Based Medicine and the Search for a Science of Clinical Care , 2005 .

[26]  K. Montgomery,et al.  How Doctors Think: Clinical Judgment and the Practice of Medicine , 2005 .

[27]  Arthur S. Reber,et al.  Cognition Unawares. (Book Reviews: Implicit Learning and Tacit Knowledge. An Essay on the Cognitive Unconscious.) , 1996 .

[28]  J. Ramirez,et al.  Hospitalization for community-acquired pneumonia: the pneumonia severity index vs clinical judgment. , 2003, Chest.

[29]  M. Gupta.  A critical appraisal of evidence-based medicine: some ethical considerations. , 2003, Journal of evaluation in clinical practice.

[30]  D. Sackett.  Evidence-based medicine: how to practice and teach EBM: 2nd ed , 2000 .

[31]  K. Roberts.  Management and outcomes of care of fever in early infancy. , 2004, The Journal of pediatrics.

[32]  A. Detsky,et al.  Evidence-based medicine. A new approach to teaching the practice of medicine. , 1992, JAMA.

[33]  A. Feinstein.  XXXIX. The haze of Bayes, the aerial palaces of decision analysis, and the computerized Ouija board , 1977 .

[34]  G. M. Goldman,et al.  The tacit dimension of clinical judgment. , 1990, The Yale journal of biology and medicine.

[35]  K. Malterud,et al.  The legitimacy of clinical knowledge: Towards a medical epistemology embracing the art of medicine , 1995, Theoretical medicine.

[36]  S. Satya‐Murti.  Evidence-based Medicine: How to Practice and Teach EBM , 1997 .

[37]  S. Tanenbaum,et al.  What physicians know. , 1993, The New England journal of medicine.

[38]  F. Davidoff,et al.  Evidence-Based Medicine: Why All The Fuss? , 1995, Annals of Internal Medicine.