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Head To Head

Does evidence based medicine adversely affect clinical judgment?

BMJ 2018; 362 doi: (Published 16 July 2018) Cite this as: BMJ 2018;362:k2799
  1. Michel Accad, cardiologist1,
  2. Darrel Francis, professor of cardiology2
  1. 1San Francisco, USA
  2. 2National Heart and Lung Institute, Imperial College, London
  1. Correspondence to: M Accad mfa{at}, D Francis d.francis{at}

For practical and theoretical reasons, says Michel Accad, evidence based medicine is flawed and leads to standardised rather than excellent individualised care, but Darrel Francis argues that it protects patients from seemingly rational actions that cause more harm than good

Yes—Michel Accad

Consider Dr Smith, a conscientious physician who keeps abreast of the medical literature and is attentive to the individual needs of her patients. Smith is well respected by her colleagues for the wisdom of her decisions.

For example, when she sees a patient with chest pain that is unlikely to be ischaemic, Smith rarely orders a stress test. She knows that the risk of a false positive result outweighs the possibility of diagnosing coronary disease.

Sometimes, however, Smith may deviate from that practice. She believes that, under certain circumstances, after considering all alternative courses of action, it may turn out to be in a patient’s best interest to disregard the objective evidence on stress tests. Can Smith be said to practise evidence based medicine (EBM)?

At first glance, proponents of EBM seem willing to answer in the affirmative and grant Smith her decisional prerogative. For example, a well established definition of the EBM is “the conscientious, explicit, and judicious use of best evidence in making decisions about the care of individual patients.”1

Judicious use of best evidence implies that evidence is subject to judgment. Depending on the circumstances, a physician can choose to apply or ignore the evidence even if the evidence is “best.” Judgment rules. Case closed.

But this lenient interpretation runs the risk of trivialising EBM. After all, what’s the point of calling attention to the importance of the evidence if that evidence can be …

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