Patient or science: Do we need to choose?

Evidence Based Medicine (henceforth EBM) has been criticized for neglecting the patient and preferring positivistic science. Positivism means that scientific proof needs to be interpreted as facts on the world. Moreover, it claims that scientific knowledge only consists of proof. [2] If EBM is really such an account of medical practice, then we will get a situation whereby we must choose between the individual patient and the hard scientific facts.

We will falsify this statement on the basis of four reasons. (i) The common definition of [4] takes into account best research evidence and clinical expertise and patient values. Moreover it is not possible in our society that a physician neglects the clinical expertise and patient values. Ethical guidelines and the rising patient empowerment make it very hard for a doctor to deny patient values. (ii) In [5] (published in the notorious The Lancet) it is argued that by using the incompleteness theorem of Gödel -which is a purely mathematical theorem on basic arithmetic- it can be shown that EBM has "shaky logical foundations". We will show that this statement is based on an incorrect assumption on Gödel; and thus that this argument cannot be taken serious. (iii) Tacit -i.e. implicit- knowledge is an important source of knowledge in clinical practice. This kind of knowledge can/will not be made explicit; ergo doing medicine is more than just research evidence and proofs. Diagnosing without tacit knowledge would probably raise the amount of misdiagnoses. An experiment by [3] shows that young practitioners know that the more experienced/older physician, the better they become. (iv) The last argument is based on social psychology insights. [1] A person who has a limited time frame will use short cuts and a person who is experienced in something will also use shortcuts to obtain her/his goal. This implicates that a physician will often use knowledge not directly based on proof or research evidence. The example of an ER doctor, who has only a very limited amount of time to decide which diagnosis is the right one, will be discussed.

These four arguments show two aspects of EBM.
1. EBM is often being misunderstood. It is not a positivistic approach to science without considering the patient.
2. If we accept argument 1, then it is not necessary to choose between the patient and science.

[1] Bargh, J.A., and Ferguson, M.J. Beyond behaviorism: On the automaticity of higher mental processes. Psychological Bulletin, 126, 2000: 925-945.
[2] Goldenberg, M.J. On evidence and evidence-based medicine: Lessons from the philosophy of science, Social Science and Medicine, 62, 2006: 2621-2632.
[3] Montgomery, K. How Doctors Think. Clinical Judgment and the Practice of Medicine. Oxford University Press, New York, 2006.
[4] Sackett, D.L., Straus, S., Richardson, S., Rosenberg, W., and Haynes, RB. Evidence-based medicine: How to practice and teach EBM. 2e edition, Churcill Livingstone, New York, 2000.
[5] Sleigh, J.W. Evidence-based medicine and Kurt Gödel, The Lancet, 346, 1995: 1172.