Evidence-Based Medicine
Source: Sackett et al., “Evidence Based Medicine: What It Is and What It Isn’t,” BMJ 312, 1996 Institution: McMaster University
Finding
David Sackett defined EBM as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” EBM established a hierarchy of evidence: systematic reviews and RCTs at the top, expert opinion at the bottom. The hierarchy ranks evidence by resistance to bias. RCTs control for confounders through randomization. Expert opinion sits at the bottom not because experts are wrong, but because individual judgment is the most susceptible to bias, selective memory, and motivated reasoning.
Pattern Mapping
Honesty — EBM is honesty formalized as methodology. The hierarchy is a hierarchy of resistance to self-deception. Blinding prevents observer bias, randomization prevents selection bias, meta-analysis prevents publication bias.
Non-fabrication — The hierarchy identifies the conditions under which medical claims are most likely fabricated (uncontrolled observation, anecdote, authority) and least likely (randomized, blinded, replicated). Expert opinion at the bottom recognizes that expertise without evidence control produces fact-shaped fiction.
Humility — EBM requires that even the most experienced clinician defer to evidence that contradicts their experience. Judgment without evidence is authority exercised beyond legitimate scope.
Connections
- Scientific Method — EBM hierarchy = formalized resistance to self-deception
- Bayesian Inference — EBM updates priors with evidence; Bayesian reasoning is its mathematical foundation
- Diagnosis — clinical diagnosis applies EBM principles at the bedside
- Traditional Medicine — the tension: EBM hierarchy vs. millennia of empirical observation
- Opioid Crisis — EBM violated when a 5-sentence letter was treated as definitive safety data
Status
Sackett et al. (1996). GRADE Working Group, BMJ 328, 2004. Critiques: Greenhalgh et al., BMJ 348, 2014 (EBM co-opted by industry). The mapping to the five properties is this project’s structural interpretation.
The mapping to the five properties is this project’s structural interpretation.