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Dear All The recent debate over the relative values in the hierarchy of research evidence has been excellent. It would appear that (as with most evidence based issues) the definition of a clear bottom line message about the hierarchy of research evidence is both complex and difficult. This debate has prompted me to ask the list about a problem that I have often considered with the evidence based practice model. If Sackett et al's definition of evidence based medicine is acceptable ( essentially evidence based medicine involves the use of quality, up-to-date reliable research evidence INTEGRATED with clinical judgement and expertise)then there would appear to be a relative imbalance in our approach to using evidence based medicine. This is because although much debate occurs over the 'quality' of research evidence, little attention is given to the value of clinical judgement. Surely even the highest level of research evidence needs clinical judgment (of equal value?) to assist in the implementation of that evidence? Is this not also one of the multi-factoral reasons why research evidence is so difficult to get into clinical practice? Apart from the existing obvious 'measurements' of clinical performance (post-graduate qualification etc.) which I presume have not been thoroughly investigated in the context of evidence based practice is anyone aware of research in this area? Thoughts and opinions would also be welcome.... Alistair Grant Cambridge UK ________________________________________________________________________ Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%