Evidence-Based Medicine Viewpoint: Moving Beyond Evidence-Based Medicine

The evidence-based medicine movement has remained both well known and controversial since its inception. The authors reframe the evidence-based medicine debate by pointing out an underappreciated epistemological deficiency: evidence-based medicine as currently conceptualized cannot accommodate concepts that resist quantitative analysis and therefore cannot logically differentiate human beings from complex machines. The authors use Michael Polanyi’s philosophy of tacit knowing (which refers to the taken-for-granted knowledge at the periphery of attention that allows persons to understand the world and discern meaning in it) as a starting point for rectifying this deficiency and for working towards an improved, personcentered epistemology of medical practice. The authors demonstrate that not only evidence-based medicine but also most traditional theories of medical practice need a concept such as tacit knowing to account for the kinds of knowledge human beings actually use. Polanyi’s philosophy of tacit knowing is defined and briefly explained. A medical epistemology that can account for the tacit dimension of human knowledge and recognize physicians and patients as persons requires a revised conception of medical uncertainty and a recognition that clinician–patient interactions are central to medicine. The authors discuss practical implications of tacit knowing for medical practice, education, research, and health care policy and suggest ways for moving beyond evidence-based medicine towards a comprehensive epistemology of medical practice. Acad Med. 2007; 82:292–297. In this article we seek to reframe the evidence-based medicine debate by focusing on an underappreciated epistemological deficiency: as currently conceptualized, evidence-based medicine cannot adequately accommodate concepts that resist quantitative analysis and therefore cannot logically differentiate human beings from complex machines. We argue that medicine needs a more robust epistemology capable of recognizing patients and clinicians as persons, and we use the concept of tacit knowing as a starting point for this project. A truly person-centered medical epistemology requires a revised conception of medical uncertainty and a recognition that clinician–patient interactions are central to medicine. We discuss practical implications of these conclusions for medical practice, education, research, and health care policy and suggest ways for moving beyond evidence-based medicine towards a comprehensive epistemology of medical