Evidence-based medicine's curious path: From clinical epidemiology to patient-centered care through decision analysis

Evidence-based medicine (EBM), one of the most important movements in health care, has been a lightning rod for controversy. Conflicts about the meaning and value of EBM are owing in part to lack of clarity about basic questions regarding its development, the importance of expertise and intuition, and the role of evidence in clinical decision making. These issues have persisted in part because of unclarity at the outset, but also because of how EBM evolved, why it was introduced when it was, and how it was modified following its introduction. This paper traces the evolution of EBM from clinical epidemiology (CE) and the internal dispute that precipitated the developers to establish EBM as a distinct approach to clinical practice. The paper proposes that health care industrialization also had a significant role in EBM's emergence and that industrialization influenced the decision to merge EBM with the method of normative decision making known as decision analysis (DA). The paper discusses the impact of this merger, in particular how it led to EBM's identification with managed care and has added momentum to the effort at forging a connection between a normative decision model and clinical judgement. This effort would turn clinical decision making into a conduit for bringing administrative rules and regulations into the consulting room and would result in expertise becoming a surplus skill. The paper closes by discussing a challenge yet unmet by EBM's advocates and critics-to chronicle the dangers that EBM in the framework of DA during the current era of industrialization poses to health and health care, and discover ways of unhinging the relationship between model and judgement.