Evidence‐based medicine's curious path: From clinical epidemiology to patient‐centered care through decision analysis

Abstract

Evidence-based medicine (EBM), one of the most important movements in health care, has been a lightning rod for controversy. Conflicts about the meaning and value of EBM are owing in part to lack of clarity about basic questions regarding its development, the importance of expertise and intuition, and the role of evidence in clinical decision making. These issues have persisted in part because of unclarity at the outset, but also because of how EBM evolved, why it was introduced when it was, and how it was modified following its introduction. This paper traces the evolution of EBM from clinical epidemiology (CE) and the internal dispute that precipitated the developers to establish EBM as a distinct approach to clinical practice. The paper proposes that health care industrialization also had a significant role in EBM's emergence and that industrialization influenced the decision to merge EBM with the method of normative decision making known as decision analysis (DA). The paper discusses the impact of this merger, in particular how it led to EBM's identification with managed care and has added momentum to the effort at forging a connection between a normative decision model and clinical judgement. This effort would turn clinical decision making into a conduit for bringing administrative rules and regulations into the consulting room and would result in expertise becoming a surplus skill. The paper closes by discussing a challenge yet unmet by EBM's advocates and critics-to chronicle the dangers that EBM in the framework of DA during the current era of industrialization poses to health and health care, and discover ways of unhinging the relationship between model and judgement.

Humans, machines and decisions: Clinical reasoning in the age of artificial intelligence, evidence‐based medicine and Covid‐19

“…The section includes papers on EBM but extends beyond EBM to broader philosophical discussions concerning clinical knowledge, causal reasoning, research and consent-discussing issues of person-centred care and the purpose of medicine, and challenges to clinical judgement presented by the need for virtual care, a need generated by the global pandemic. [17][18][19][20][21][22][23][24][25][26][27] The first three papers in the section [17][18][19] take up the issues that were the topic of the concluding papers in the preceding 'Humanities' section, 15,16 though in this case the author outlines the history of the EBM debate from the perspective of medical philosophy and the history of ideas. The papers provide an extremely helpful account and critical analysis of the debate over the last 30 years, concluding with arguments concerning the possibilities for future development and the relationship between EBM and complexity theory, providerpatient decision making and person-centred care.…”

“…They are followed by two challenging papers designed to raise awareness of factors that have influenced the development of the evidence hierarchies that inform EBM 20 and to trace EBM's 'curious path' from clinical epidemiology to patient-centred care. 21 Following this 'path' reveals an as-yet unmet challenge to both advocates and critics of EBM, to chronicle the dangers that EBM, in the framework of decision-analysis, poses to health and health care during the current era of industrialization. 21 The issues of person-centred care, the value of knowledge and the disconnect between currently dominant theoretical models of reasoning on the one hand, and real-world reasoning on the other, are brought out in a fascinating discussion of 'transdisciplinary generalism'.…”

“…21 Following this 'path' reveals an as-yet unmet challenge to both advocates and critics of EBM, to chronicle the dangers that EBM, in the framework of decision-analysis, poses to health and health care during the current era of industrialization. 21 The issues of person-centred care, the value of knowledge and the disconnect between currently dominant theoretical models of reasoning on the one hand, and real-world reasoning on the other, are brought out in a fascinating discussion of 'transdisciplinary generalism'. 22 The paper provides a rich alternative to opposing 'reductionist (positivist) biomedical measures and social science (post-positivist) constructivist theories of knowledge' and it is followed by a similarly rich discussion of causal reasoning with application to specific cases 23 The focus on the need to develop theories of knowledge and judgement that make sense in the context of practice continues with papers on consent and the purpose of medicine 24,25 and a detailed and instructive account of the transition 'from inquiry to evidence to actionable clinical knowledge'.…”

“…The papers that form the section to follow address the broad issues of clinical reasoning, evidence, judgement and explanation. The section includes papers on EBM but extends beyond EBM to broader philosophical discussions concerning clinical knowledge, causal reasoning, research and consent—discussing issues of person‐centred care and the purpose of medicine, and challenges to clinical judgement presented by the need for virtual care, a need generated by the global pandemic 17‐27 …”

“…The papers provide an extremely helpful account and critical analysis of the debate over the last 30 years, concluding with arguments concerning the possibilities for future development and the relationship between EBM and complexity theory, provider‐patient decision making and person‐centred care. They are followed by two challenging papers designed to raise awareness of factors that have influenced the development of the evidence hierarchies that inform EBM 20 and to trace EBM's ‘curious path’ from clinical epidemiology to patient‐centred care 21 . Following this ‘path’ reveals an as‐yet unmet challenge to both advocates and critics of EBM, to chronicle the dangers that EBM, in the framework of decision‐analysis, poses to health and health care during the current era of industrialization 21 …”