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Feb 05, 2010

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The definition of evidence based medicine cited in this post appears to be only a first sentence from an editorial in the British medical Journal (BMJ 1996;312:71-72). The next two qualifying sentences are sadly generally neglected. Here are all three.


Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.

It is easier to deal with external clinical evidence and rate its quality as GRADE describes. We cannot do the same with clinical expertise, although the term can also apply to evidence of a lesser quality categorized as “expert opinion”.

But clinical expertise can also refer to an attribute that is in a different category.

These two attributes, external clinical evidence and individual clinical expertise, reflect the relationship between data derived from the study of populations and its application to individual cases. No matter what tools we might use to accomplish this with precision, some uncertainty can always remain because of the uniqueness of the individual.

Consideration of the messy concept of "clinical judgement" is unavoidable, even though it is admittedly treacherous territory. This certainly does not mean entering the nonsensical world that includes homeopathy and the like.

Individuals possess unique attributes requiring judgement in the application of evidence derived from population studies. Doing so remains a methodological challenge.


Dr. Sonnabend is correct that I used the first sentence of the EBM definition from the BMJ editorial, but that first sentence has widely circulated as a standard definition of EBM. I think it's a reasonable one to use.

To my mind, "clinical expertise" (or "expert opinion" if you prefer) is always needed to translate any quality of evidence into recommendations for clinical practice. Evidence alone does not get you to recommendations.

In contrast, "clinical experience" (or "clinical observation") is best considered a type of evidence. If this distinction is maintained between the evidence and the expertise to interpret the evidence, I think it makes discussions of clinical knowledge a lot clearer.

A very interesting debate. I think the GRADE methodology provides a approach to issues of patient centered instead of
Focused on the disease. What matters are the results on health, not intermediate results.
GRADE report is a transparent approach about the source of the evidence found and the strength of the recommendation. Now clinical guidelines do not share common assessment methodologies. Grade is a great opportunity.

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