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Evidence based medicine—an oral history

BMJ 2014; 348 doi: (Published 21 January 2014) Cite this as: BMJ 2014;348:g371

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Re: Evidence based medicine—an oral history

The Editorial and video “Evidence Based Medicine-an oral history,” gives me an opportunity to reflect on my experience at McMaster as a medical student in its fourth class, and a resident in internal medicine and cardiology after, and thus a part of the early stirrings of evidence based medicine (1). This, and later experiences led me to a different thinking, however, of McMaster as a complexity medical school, and to propose a complexity based medicine, to update evidence based medicine with complexity, the science for the 21st century according to Stephen Hawking (2,3).

Complexity is a 21st century science emerging from systems and chaos science that describe the complex dynamic interactions of our interconnected and interdependent world, and guides change (2-4). I suggest that McMaster should be equally recognized for its complexity innovation as for problem based learning, considered one of the three major reforms in medical education in the 20th century.

The McMaster medical program was nonhierarchical, non-expert-tutor facilitated, with self-directed, small group, interdisciplinary learning, with nonlinearity, feedback, adaptation and change, and uncertainty and emergence of ideas, many features of complexity science. It moved away from the traditional top-down didactic lecture and rigid course based basic science followed by clinicals curriculum to problem based and integrated, with patient contact at the onset. Interactions were complex, dynamic and nonlinear, leading to emergent learner-centered-learning and assessment, reflecting complexity.

Evidence based medicine emerged out of this complexity thinking and practice to simplify matters. This was a mechanistic and reductionist 17th century science approach that served medicine well, but with significant limitations. With “scientific medicine” initially considered for its name, it appeared to take the art, context and messiness out of medicine, with research and facts that could not be applied to individuals and the context of their complex diverse reality.

Complexity in medicine and patients’ lives illustrate the need to put the art, context and complexity back into evidence, much beyond clinical skills, patient values and preferences (4). Hence a proposal for complexity based medicine to update evidence based medicine, using the 21st century science of complexity as a translation factor to individuals and reality.

Future trends, with greater web-like interconnections, interdependence, social innovation, crowdsourcing, technology, big data, network science and patient-centered-care, providing newer kinds of information, evidence and practice, make this even more necessary.

1. Evidence based medicine-an oral history. Editorial. BMJ 2014;348:g371

2. Rambihar VS. Complexity Based Medicine: Evidence based medicine at the edge of chaos. accessed 30 January 2014

3. Rambihar VS. A New Chaos Based Medicine Beyond 2000: the response to evidence. 1999. Vashna Publications Toronto.

4. Rambihar Vivian S, Rambihar Vanessa S. Complexity the science for medicine and the human story. Lancet 2010;375;8721.

Competing interests: I am a graduate of McMaster University medical school in its early days, (which I call a complexity medical school), at the time of the early stirrings of evidence based medicine.

31 January 2014
Vivian S Rambihar
Adjunct Assitant Professor of Medicine, University of Toronto
3000 Lawrence Ave E, Suite 3302