Listening in on the "should I practice EBM?" conversations, my fingers began
to itch. Here's some more stuff for y'all to scratch:
If I accept some premises:
z. clinical practice could be informed by knowledge from several sources,
such as from clinical experience & expertise, from basic sciences of human
health & disease, from what the patient tells us, from the context of care,
from clinical care research, from clinical ethics, and others.
y. each kind of knowledge is both a WAY OF KNOWING and an expanding
collection of THINGS KNOWN that way.
x. each kind of knowledge could have strengths and limitations.
w. human judgment is the capacity of selecting, weighing and integrating
pieces of knowledge. Thus, integrating two or more kinds of knowledge
requires the exercise of judgment.
v. clinical work involves making particular judgments, predictions,
decisions, actions and recommendations, by applying general knowledge to the
And if I set my purpose to practice wisely, that is, make judgments,
predictions, decisions, actions and recommendations that best influence the
wellbeing of my [choose one or more of the following to fit your
circumstance] a. patient; or b. local population; or c. national or global
Then, I might reason that:
1. for each source of knowledge, I'd like to be able to tell the better from
the not-so-good [hence, I need some way to tell which bits are likely to be
true and important]
2. for each source of knowledge, I may need help moving from those
individual facts to how to integrate that fact into practice [thus, some way
to tell which bits are applicable to my situation, and how exactly to
actually use 'em]
3. to practice wisely, I should learn how to use any form of knowledge that,
if I understood it and used it well, could meaningfully influence the
well-being of my patient/population. [Here's where it's useful to have
stories of instances where evidence can/should/did change practice
dramatically, e.g. the CAST for post MI Rx, the NASCET, etc. If a form of
knowledge is often useful, do we need to require that it always be useful?
Don't think so.]
4. it becomes more a matter of HOW [How exactly? How accurately? How
efficiently? How practically? How wisely? Etc] rather than WHETHER to use
Indeed, I would imagine skeptics might find it very difficult to defend a
position that clinical practice should NEVER be informed by knowledge from
one of those sources. Can anyone make a compelling case for abandoning
forever the use of knowledge gained from basic science research? Can anyone
seriously defend the position that clinical practice should be carried out
by folks completely devoid of clinical expertise? Similarly, can anyone
defend the stance that we should forever ignore the findings of decades of
clinical care research? Isn't that position extreme?
Instead of whether to ever use evidence from clinical care research, don't
we really want to discuss how to use such evidence wisely, along with other
knowledge, in caring for patients and/or populations? Isn't EBP/EBHC about
adding evidence to the mix of things we use to inform our work, rather than
substituting it for other knowledge?
W. Scott Richardson, M.D.
Audie L. Murphy Memorial Veterans Hospital *******************
7400 Merton Minter Blvd. violets
San Antonio, TX 78284 how precious on
T: (210) 617-5238 a mountain path
F: (210) 617-5234 Basho
Email: [log in to unmask] *******************