Inverting the Evidence Hierarchy

Abstract

When David Sackett launched his program as the founder Director of Oxford’s Centre for Evidence Based Medicine, he defined the field (in his seminal book, How to Practice and Teach EBM) as combining best research evidence with clinical experience and with individual patients’ values. Yet contemporary evidence-based medicine is largely taken up with the first of these, with best research evidence. Clinical experience is all-too-often subordinated to evidence-based guidelines: these are indeed only guidelines, not, as Gill Leng the Deputy Director of NICE repeatedly reminds us, tram lines; but clinical experience is in practice subordinated by them, nonetheless. While as to individual patients’ values, the third element of David Sackett’s original definition, individual case histories, as the vehicle for understanding what matters or is important to a given patient, come right at the bottom of the hierarchy of contemporary EBM.