The Problem of Evidence-Based Medicine: Directions for Social Science

Department of Community Health and Epidemiology, Centre for Clinical Research, Dalhousie University, 4th Floor-5790 University Ave. Halifax, NS, Canada B3H 1V7.
Social Science & Medicine (Impact Factor: 2.89). 10/2004; 59(5):1059-69. DOI: 10.1016/j.socscimed.2003.12.002
Source: PubMed


Evidence-based medicine (EBM) is arguably the most important contemporary initiative committed to reshaping biomedical reason and practice. The move to establish scientific research as a fundamental ground of medical decision making has met with an enthusiastic reception within academic medicine, but has also generated considerable controversy. EBM and the broader forms of evidence-based decision making it has occasioned raise provocative questions about the relation of scientific knowledge to social action across a variety of domains. Social science inquiry about EBM has not yet reached the scale one might expect, given the breadth and significance of the phenomenon. This paper contributes reflections, critique and analysis aimed at helping to build a more robust social science investigation of EBM. The paper begins with a "diagnostics" of the existing social science literature on EBM, emphasizing the possibilities and limitations of its two central organizing analytic perspectives: political economy and humanism. We further explore emerging trends in the literature including a turn to original empirical investigation and the embrace of "newer" theoretical resources such as postmodern critique. We argue for the need to move the social inquiry of EBM beyond concerns about rationalization and the potential erasure of the patient and, to this end, suggest new avenues of exploration. The latter include analysis of clinical epidemiology and clinical reason as the discursive preconditions of EBM, the role of the patient as a site for the production of evidence, and the textually mediated character of EBM.

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    • "Evidence-Based Practice Paradigm Rooted in Bevidence-based medicine^, the term was officially coined in Canada over 25 years ago (Evidence-based Medicine Working Group 1992). Since then it has been upheld by international organizations such as the Cochrane Collaboration and has branched out across the professional disciplines (Mykhalovskiy and Weir 2004, p. 1060). EBP refers to the conscientious, explicit, and thoughtful use of the best available evidence in decision-making in order to deliver services that are safe and the most effective (Sackett et al. 2000). "
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    • "Mykhalovskiy and Weir (2004) see evidence based practice providing a new arena for social sciences within medicine; not sidelined by medicine and medical/biological methodologies. Social sciences have the capacity to illuminate 'discursive preconditions' of evidence based practice (Mykhalovskiy and Weir 2004:1060), are able to recognise the community and cultural context of the 'patient' or 'service user', and can provide methodologies with which to critique bio-medical evidence and offer manifold perspectives (Marks 2002). "
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    • "Such work tends to invoke binary oppositions between evidence and values, science and art, and standardization and personalization. In order to empirically investigate, rather than reproduce, such dichotomies, social scientists are starting to ask new questions; how does EBM create new (representations of) patients, and what kinds of choices do EBM tools support or ignore (Mykhalovskiy and Weir, 2004). For example, Brody and colleagues reject the notion that EBM is more or less patient-centered than other forms of medicine but suggest EBM shifts from one type of standardized patient to another: away from pathophysiology – where 'individual patients' are represented by their organs, lab results, or molecules – towards the study of populations – where a patient may be represented by his/her age, gender, body weight, or behavior (smoking, diet, exercise, and work). "
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