The evidence‐based paradox and the question of the Tree of Knowledge

Framing the EBM debate: a commentary on Saad (2008)

“…My initial reaction on reading Dr Saad's article [1] was to reach for what the author Robert Pirsig would disparagingly call my ‘philosopher’s knife' [2], to slice the little paper into pieces. That, however, would be not only counterproductive, but very unfair.…”

“…One might, after about 15 years of EBM, expect those convinced of its superiority to ‘traditional medicine’ to have offered something that they might be prepared to admit as ‘evidence’ in support of this fundamental claim. Saad notes that the question ‘Do we have any evidence that evidence‐based medicine indeed improves clinical outcomes?’ has been raised repeatedly, both by defenders and critics of EBM [1] and notes further that EBM protagonists announced at the outset that ‘no long‐term randomized control trials of traditional and evidence‐based education are likely to be carried out’[9].…”

“…I would have expected Saad to be as perplexed as I was [10] by the ease with which such enthusiasts for research pronounce research into their own claims unnecessary, insisting, for instance, that while ‘a comprehensive research program that looked at the effect of evidence‐based practice on error reduction’ would be a ‘worthy and interesting project’, it is somehow not worthy enough to be actually considered – before asserting that their own assumptions on the matter are ‘probably true’ even while admitting ( in the same sentence [11]) that they lack ‘evidentiary support’. Ignoring such explanations as the fact that we ‘have our hands full already’[11], Saad mentions practical obstacles that apologists for EBM have asserted ‘stand in the way of such trials’[1]. He makes some helpful and straightforward comments sketching what a suitable empirical test for EBM might look like before apparently coming to the rescue of such apologists, introducing ‘the sceptic’ to question the test's utility.…”

“…On a re‐reading, however, I realize Saad's use of this argument is more subtle than I originally appreciated. In my keenness to slice up the sceptical argument I missed the rather obvious point that Saad does not say that the argument succeeds in proving the existence of a ‘dilemma’– he simply raises the question ‘does it’ confront us with a ‘problematic dilemma’ and states that it is in answering this question he hopes to ‘shed some light on EBM’s status' [1]. What follows is a very persuasive argument about the way clinical trials impact upon practice, to the effect that we should construe such trials as ‘interventions’, and a closely related argument that the value of any such intervention in practice depends, necessarily, on the intuitions of the physician using it.…”

“…The interpretation of the criteria or guidelines and assessment of their relevance to the problem at hand must be part of the decision as to whether, to what extent and in what manner to apply them in any given scenario. And how well or badly people perform these tasks is determined by the quality of their intuitive responses: as Saad puts it, ‘it is intuition the whole way down’[1].…”