The Role of Evidence-Based Medicine

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Smith's recent response1 to our analysis of evidence-based medicine2 offers useful insights but misinterprets important aspects of our argument.
We never suggested that tacit knowing should replace evidence-based medicine and, in fact, emphasized that the “epidemiological studies evidence-based medicine promotes are important tools for improving medical care.”2 Clinical epidemiology, the foundation for evidence-based medicine, is indispensable for good clinical practice, but it remains one among several tools available to clinicians. Tacit knowing is not a clinical tool, but its existence and importance in medicine demonstrate that attempts to make evidence-based medicine the sole “keeper of the rules”1 for determining truth simply cannot work. Clinicians should not ignore, for example, Koch's postulates in microbiology. Asserting that evidence-based medicine is inadequate or even philosophically incoherent is not equivalent to asserting that clinical epidemiology's widely accepted methods should be abandoned, that outcomes cannot or should not be rigorously evaluated, or that medical education should be “humanized” through deconstructionism or relativism.
We agree with Michael Polanyi's assertion that discoveries take place within and should be evaluated by expert communities, but evidence-based medicine promotes precisely the kind of positivist, unrealistic conception of knowledge that Polanyi spent decades trying (unsuccessfully) to overturn.
After Smith's spirited attack on our “faith-based claims,” he unexpectedly goes on to endorse our contention that evidence-based medicine should not be the sole determinant of clinical decisions and suggests, as did we, that other methods and disciplines are needed to complement evidence-based medicine. He also supports our emphasis on the patient as person and the importance of apprenticeship (rather than simulation) in medical education. These statements and his subsequent comments make us wonder whether his dismissal of our article as a straw man argument stems from substantive disagreement or merely disagreement about the definition of evidence-based medicine. If the latter is correct, it supports our contention that the term evidence-based medicine is tendentious and, despite its rhetorical force, may have outlived its usefulness in academic medicine.
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