Debates about how knowledge is made and valued in evidence-based medicine (EBM) have yet to understand what discursive, social, and historical conditions allowed the EBM approach to stabilize and proliferate across western medical education. This paper uses a genealogical approach to examine the epistemological tensions that emerged as a result of various problematizations of uncertainty in medical practice. I explain how the problematization of uncertainty in the literature and the contingency of specific social, political, economic, and historical relations allowed the EBM approach to become a programmatic and pedagogical focus of the Faculty of Medicine at McMaster University and beyond.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Barrows, Howard S. 1996. "Problem-based Learning in Medicine and Beyond: A Brief Overview." New Directions for Teaching and Learning 68:3. doi:10.1002/tl.37219966804.
Battista, Renaldo N. and Matthew J. Hodge. 1993. “Clinical Practice Guidelines: Between Science and Art.” CMAJ 148 (3): 385-389.
Bell, Bertrand M. 1995. “Error in Medicine.” JAMA 274 (6): 458.
Bahtsevani, Christel, Giggi Ud´en, and Ania Willman. 2004. “Outcomes of Evidence-based Clinical Practice Guidelines: A Systematic Review.” International Journal of Technology Assessment in Health Care 20 (4): 427–433.
Beauchamp, Tom L. and Yashar Saghai. 2012. “The Historical Foundations of the Research-Practice Distinction in Bioethics.” Theoretical Medicine 33 (1): 45-56.
Boardman, Donnelle W. 1974. “The Dollars and Sense of Medical Care and Health Services: Relation.” New England Journal of Medicine 291 (10): 497-502.
Braude, Hillel D. 2009. “Clinical Intuition versus Statistics: Different Modes of Tacit Knowledge in Clinical Epidemiology and Evidence-based Medicine.” Theoretical Medicine and Bioethics 30:181-198.
Caplan, Robert A., Karen Posner, and Frederick W. Cheney. 1991. “Effect of Outcome on Physician Judgments of Appropriateness of Care.” JAMA 265 (15): 1957-1960.
Chalmers, Iain. 2001. “Comparing Like with Like: Some Historical Milestones in the Evolution of Methods to create unbiased Comparison Groups in Therapeutic Experiments.” International Journal of Epidemiology 30:1156-1164.
Cochrane Collaboration, The. 2013. “Our History.” Accessed January 3, 2014. http://ukcc.cochrane.org/our-history.
Datta, Ronjon Paul. 2007. “From Foucault’s Genealogy to Aleatory Materialism: Realism, Nominalism, and Politics.” In Critical Realism and the Social Sciences: Heterodox Elaborations, edited by Jon Frauley and Frank Pearce, 271-295. Toronto, Canada: University of Toronto Press.
Daly, Jeanne. 2005. Evidence-based Medicine and the Search for a Science of Clinical Care. Berkeley, CA: University of California Press.
Davidoff, Frank, Brian Haynes, Dave Sackett, and Richard Smith. 1995. “Evidence-Based Medicine.” BMJ 310:1085.
Davis, David A., Mary Ann Thomson, Andrew D. Oxman, and R. Brian Haynes. 1992. “Evidence for the Effectiveness of CME: A Review of 50 Randomized Controlled Trials.” JAMA 268 (9): 1111-1117.
Davis, Milton S. 1968. “Variations in Patients’ Compliance with Doctors’ Advice: An Empirical Analysis of Patterns of Communication.” American Journal of Public Health 58 (2): 274-288.
Eddy, David M. 1990. “The Challenge.” JAMA 263 (2): 287-290.
Ellis, J., I. Mulligan, J. Rowe, and D.L. Sackett. 1995. “Inpatient General Medicine is Evidence Based.” Lancet 346:407–410.
“Evidence-Based Medicine, In its Place.” 1995. The Lancet 346 (8978): 785.
Feinstein, Alvan R. 1967. Clinical Judgment. Baltimore, MD: The Williams & Wilkins Company.
Feinstein, Alvan R. and Walter O. Spitzer. 1988. “The Journal of Clinical Epidemiology: Same Wine, new Label for the Journal of Chronic Diseases.” Journal of Clinical Epidemiology 41 (1): 1-7.
Flarragin, Annette and George D. Lundberg. 1990. “Clinical Decision Making: Promoting the Jump from Theory to Practice.” JAMA 263 (2): 279-280.
Fletcher, Robert H., Suzanne W. Fletcher, and Howard H. Wagner. 1982. Clinical Epidemiology – the Essentials. Baltimore, MD: Williams & Wilkins.
------. 1996. Clinical Epidemiology – the Essentials. Third Edition. Baltimore, MD: Williams & Wilkins.
Foucault, Michel. 1973. The Birth of the Clinic. New York: Pantheon Books.
------. 1988. “On Problematization.” History of the Present 4:16-17.
------. 1994. “The Will to Knowledge.” In Ethics, Subjectivity and Truth, edited by Paul Rabinow, 11-16. New York: The New Press.
------. 2003. “Questions of Method.” In The Essential Foucault, edited by Paul Rabinow and Nikolas Rose, 246-258. The New York Press.
Goldenberg, Maya. 2010. “Clinical Evidence and the Absent Body in Medicine Phenomenology: On the Need for a new Phenomenology of Medicine.” The International Journal of Feminist Approaches to Bioethics 3 (1): 43-71.
Guyatt, Gordon, John Cairns, David Churchill, Deborah Cook, Brian Haynes, Jack Hirsh, Jan Irvine, Mark Levine, Mitchell Levine, Jim Nishikawa, and David Sackett. 1992. “Evidence-Based Medicine: A new Approach to Teaching the Practice of Medicine.” JAMA 268 (17): 2420-2425.
Guyatt, Gordon, David L. Sackett, and Debra Cook. 1993. “Users’ Guides to the Medical Literature--How to Use an Article about Therapy or Prevention.--Are the Results of the Study Valid?.” JAMA 270 (21): 2598-2601.
Health Canada. 2004. “Royal Commission on Health Services, 1961 to 1964.” Accessed January 3, 2014. http://www.hc-sc.gc.ca/hcs-sss/com/fed/hall-eng.php.
Hill, Austin Bradford. 1948. “Streptomycin Treatment of Pulmonary Tuberculosis.” BMJ 2:769-783.
Howick, Jeremy H. 2011. Philosophy of Evidence-based Medicine. Hoboken, NJ: Wiley-Blackwell.
HMSO. 1971. A Framework for Government Research and Development. Cmnd. 4814, HMSO: London.
International Clinical Epidemiology Network. 2013. “INCLEN.” Accessed February 20, 2013. http://www.inclen.org/.
Kidd, M.G. and J. T. H. Connor. 2008. “Striving to do Good Things: Teaching Humanities in Canadian Medical Schools.” Journal of Medical Humanities 29 (1): 45-54.
King, Lester S.1983. “Medicine Seeks to be ‘Scientific’.” JAMA 249 (18): 2475-2479.
Kleinman, Arthur. 1997. Writing at the Margin: Discourse between Anthropology and Medicine. California Scholarship Online. doi: 10.1525/california/9780520209657.001.0001.
Laffel, Glenn L. and Donald M. Berwick. 1993. “Quality Health Care.” JAMA 270 (2): 254-255.
Leape, LL. 1994. “Error in Medicine.” JAMA 272:1851-1857.
Ludmerer, Kenneth. 1985. Learning to Heal: The Development of American Medical Education. Baltimore, MD: Johns Hopkins University Press.
------. 2005. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. Oxford, UK: Oxford University Press.
Light, Jr., Donald. 1979. “Uncertainty and Control in Professional Training.” Journal of Health and Social Behavior 20:310-322.
Marcum, James A.2009. “The Epistemically Virtuous Clinician.”Theoretical Medicine and Bioethics 30:249-265.
Marks, Harry. 1997. The Progress of Experiment: Science and Therapeutic Reform in the United States, 1900-1990. New York: Cambridge University Press.
Massachusetts Medical Society. 2013. “MMS Annual Oration.” Accessed January 2, 2014. http://www.massmed.org/About/MMS-Leadership/History/MMS-Annual-Oration/#.UecejZyAEmE.
McKibbon, Kathleen Ann, Nancy L Wilczynski, and Robert Brian Haynes. 2004. “What do Evidence-based Secondary Journals tell us about the Publication of Clinically Important Articles in Primary Healthcare Journals?” BMC Medicine 2 (33). doi:10.1186/1741-7015-2-33.
Merz, Beverly. 1983. “Medical Decision-Making: Analyzing Options in the Face of Uncertainty.” JAMA 249 (16): 2133-2142.
Mishler, Elliot G. 1981. “Viewpoint: Critical Perspectives on the Biomedical Model.” In Social Contexts of Health, Illness, and Patient Care, edited by Elliot G. Mishler, 1-23. Cambridge, UK: Cambridge University Press.
Mulley, Albert G. 1988. “What is Inappropriate Care?” JAMA 260 (4): 540-541.
Mykhalovskiy, Eric and Lorna Weir. 2004. “The Problem of Evidence-Based Medicine: Directions for Social Science.” Social Science & Medicine 59:1059-1069.
Nuland, Sherwin B. 2008. The Uncertain Art: Thoughts on a Life in Medicine. New York: Random House.
O’Reilly, M. 1997. “Evidence-based Medicine Designed to Save Physicians' Time, Energy, FPs told.” CMAJ 156:1457–1458.
Osborne, Thomas and Nikolas Rose. 1997. “In the Name of Society, or Three Theses on the History of Social Thought.” History of the Human Sciences 10:87-104.
Paul, John R. 1938. “Clinical Epidemiology.” The Journal of Clinical Investigation 17 (5): 539-541.
Pease, Elizabeth. 1981. “Decisions.” JAMA 246 (15): 1731.
Rafuse, Jill. 1994. “CMA's March Leadership Conference aims to bring Practice, Research Closer Together.” CMAJ 150 (2): 250-251.
Refelmeier, Donald A. and Eldar Shafir. 1995. “Medical Decision Making in Situations that offer Multiple Alternatives.” JAMA 273 (2): 302-305.
Reiser, Stanley Joel. 1993. “The Era of the Patient: Using the Experience of Illness in Shaping the Missions of Health Care.” JAMA 269 (8): 1012-1017.
Reverby, Susan. 1981. “Stealing the Golden Eggs: Ernest Amory Codman and the Science and Management of Medicine.” Bulletin of the History of Medicine 55:156-171.
Rosenberg, Charles. 1977. “Therapeutic Revolution: Medicine, Meaning, and Social Change in Nineteenth Century America.” Perspectives in Biology and Medicine 20 (4):485-506.
Richardson, W. Scott, Mark C. Wilson, Gordon H, Guyatt, Deborah J. Cook, and James Nishikawa. 1999. “Users’ Guide to the Medical Literature-- How to Use an Article about Disease Probability for Differential Diagnosis.” JAMA 281 (13): 1214-1219.
Sackett, David M. 1969. “Clinical Epidemiology.” Journal of American Epidemiology 89 (2): 125-128.
------. 2002. “Clinical Epidemiology: Who, What, and Whither.” Journal of Clinical Epidemiology 55:1161-1166.
Sackett, David M. and Marjorie S. Baskin. 1971. Methods of Health Care Evaluation. Hamilton, Canada: McMaster University.
Sackett, David L., William M C Rosenberg, J A Muir Gray, R Brian Haynes, and W Scott Richardson. 1996. “Evidence-Based Medicine: What it is and isn’t.” BMJ 312:71-72.
Sackett, David L., Sharon E. Straus, W. Scott Richardson, and R. Brian Haynes. 2000. Evidence-Based Medicine: How to Practice and Teach EBM. Toronto, Canada: Churchill Livingstone.
Schoenbaum, Stephen C. 1993. “Toward Fewer Procedures and Better Outcomes.” JAMA 269 (6): 794-796.
Schroeder, Steven A., Jane S. Zones, and Jonathan A. Showstack. 1989. “Academic Medicine as a Public Trust.” JAMA 262 (6): 803-812.
Silverstein, Marc D. 1988. “Prediction Instruments and Clinical Judgments in Critical Care.” JAMA 260 (12): 1758-1759.
Sudnow, David. 1967. “Dead On Arrival.” Society 5 (1): 36-43.
Tosteson, Daniel C. 1990. “New Pathways in General Medical Education.” New England Journal of Medicine 322:234-238.
Tuckett, D., M. Boulton, C. Olson and A. Williams. 1985. Meetings between Experts. An Approach to Sharing Ideas in Medical Consultations. New York: Routledge.
Upshur, R.E.G. and Errol Colak. 2003. “Argumentation and Evidence.” Theoretical Medicine and Bioethics 24:283-299.
Walters, William. 2012. Governmentality: Critical Encounters. New York: Routledge.
Warner, John Harley. 1986. The Therapeutic Perspective. Cambridge, MA: Harvard University Press.
Waugh, Douglas. 1984. “Medical Education: Challenges of the Future.” Canadian Medical Association Journal 131:145-146.
Wennberg, John and Alan Gittelsohn. 1973. “Small Area Variations in Health Care Delivery.” Science 182 (117): 1102-1108.
White, Kerr L., Franklin Williams, and Bernard G. Greenberg. 1961. “Ecology of Medical Care.” New England Journal of Medicine 265:885-892.
Wulff, Hendrik R.. 1976. Rational Diagnosis and Treatment. Oxford, UK: Blackwell Scientific Publications.
Zarkovich, Erica and R.E.G. Upshur. 2002. “The Virtues of Ethics.” Theoretical Medicine and Bioethics 23:403-412.
Archives of Ontario, Record Group 32-23, Box B356178. 1971. Health Facilities.
Archives of Ontario, Record Group 32-23, Box B356178. 1971. June Newsletter of “Forum”.
Archives of Ontario, Record Group 32-23, Box B354145. January 13, 1961. Report, “McMaster University and Medical Education,” from Vice-President and Director of Research H.G. Thode to Premier Robarts.
Archives of Ontario, Record Group 32-23, Box B354145. 1963. Minutes, McMaster University and the Committee of University Affairs.
Archives of Ontario, Record Group 32-11, Box B241011. 1964. Committee of University Affairs Issues Books.
Archives of Ontario, Record Group 32-54, Box B177915. 1964. Memo, Minister of University Affairs, for the information of the prime minister [i.e., premier] RE: Report of the Royal Commission on Health Services.
Archives of Ontario, Record Group 32-23, Box B354530. 1968. Report on the Committee on University Affairs.
Archives of Ontario, Record Group 32-54, Box B177915. 1966. Report, McMaster University for the Committee on University Affairs.
Archives of Ontario, Record Group 32-2. Box B167431. 1969. Minutes, Committee on University Affairs.
Archives of Ontario, Record Group 32-23, Box B350860. 1969. Ontario Health Resources Development Fund for Capital Construction.
McMaster University Faculty of Health Sciences Archives, Series: Papers of J.R. Evans 145.8, Box 44. n.d. History.
McMaster University Faculty of Health Sciences Archives, Series: Papers of J.R. Evans 144.6, Box 33. n.d. Prospectus.
McMaster University Faculty of Health Sciences Archives, Series: Papers of J.R. Evans 146.2, Box 47. March 1956. Letter from President Gilmour to the Ontario Minister of Education, W.J. Dunlop.
McMaster University Faculty of Health Sciences Archives, Series: Papers of J.R. Evans, 146.2, Box 47. February 17, 1964. Letter from M.B. Dymond, Minister of Health, to Hon. John P. Robarts, Premier of Ontario.
McMaster University Faculty of Health Sciences Archives, Series: Papers of J.R. Evans 145.8, Box 44. 1966. Objectives.
McMaster University Faculty of Health Sciences Archives, Series Clinical Epidemiology & Biostatistics 184.5, Box 001. 1969. Objectives of the Faculty of Medicine of McMaster University.
McMaster University Faculty of Health Sciences Archives, Series Papers of J.R. Evans 144.7, Box 34. 1969. Educational Objectives in the Undergraduate Medical Curriculum.
McMaster University Faculty of Health Sciences Archives, Series Papers of J.R. Evans 146.2, Box 47. June 18 1971. Letter from H.H. Walker, Deputy Minister of Education.
McMaster University Faculty of Health Sciences Archives, Series Clinical Epidemiology & Biostatistics 184.5, Box 002. 1971. National Seminar on Health Care Evaluation.
McMaster University Faculty of Health Sciences Archives, Series Papers of J.R. Evans 145.8, Box 44. 1972. Revised Statement of General Goals – M.D. Program.
McMaster University Faculty of Health Sciences Archives, Series Clinical Epidemiology & Biostatistics 184.5, Box 001. 1972. Objectives: Department of Clinical Epidemiology and Biostatistics.
McMaster University Faculty of Health Sciences Archives, Series Clinical Epidemiology & Biostatistics 184.5. Box 001, 1972. Health Services Research: A Declaration of Intent: 1969-72.
McMaster University Faculty of Health Sciences Archives, Series Education: Victor Neufeld 215.6 Box 003. 1981. A Course on Critical Appraisal of Data.
McMaster University Faculty of Health Sciences Archives, Series: Papers of J.F. Mustard 151.5, Box 33. 1982. Annual Report, July 1, 1980 – June 30, 1982.
McMaster University Faculty of Health Sciences Archives, Series Education: Victor Neufeld 215.6 Box 003. 1983. Report of First Annual Meeting of INCLEN.
McMaster University Faculty of Health Sciences Archives, Series Clinical Epidemiology & Biostatistics 184.5, Box 001. 1991. Department of CE&B Five-Year Overview 1986-1991.
McMaster University Faculty of Health Sciences Archives, Series Clinical Epidemiology & Biostatistics 184.5, Box 001. 1994. Department Overview.
McMaster University Faculty of Health Sciences Archives, Series Clinical Epidemiology & Biostatistics 184.5, Box 001. 2000. CE&B Newsletter.
National Archives, Record Group UGC 30/71. 1971. Medical Research Council Response to the Rothchild Report.
This research was supported by the Department of Sociology at the University of Alberta, the Social Sciences and Humanities Research Council of Canada, and the Killam Trusts at Dalhousie University. I would also like to thank Zohreh BayatRizi, Robyn Braun, Tim Caulfield, Ronjon Paul Datta, Brendan Leier, Anne McKeage, Tara Milbrandt, Braden O’Neill, and Christopher Schneider for their contributions to this project.
1 For example, Charles Rosenberg’s (1977) article on the “Therapeutic Revolution,” Susan Reverby’s (1981) article on Ernest Amory Codman, and John Warner’s (1986) work on the tensions between empirical and rational thinking in medicine are excellent sources for interrogating the assertion that EBM introduced scientific evidence into clinical practice. The focus of this paper is not whether EBM was “new,” but rather how EBM was the result of a specific problematization of clinical practice which would incite reform to medical training and education.
2 The field of medicine understands the nature of medical practice to be ambiguous due to the impossible nature of knowing the outcome of any medical decision or intervention in advance (e.g., see Nuland 2008). Also see the historical work of Kenneth Ludmerer (e.g., 1985, 2005) regarding the centrality of uncertainty in the development of medical education curricula.
3 For an excellent discussion of these topics, see Harry Marks’ (1997) The Progress of Experiment.
4 Marks (1997), for example, documented various forms of resistance to the scientific model from within medicine.
5 Rheumatic fever is a condition that may develop in the heart after a Streptococcus A bacterial infection, affecting the heart, joints, skin, or brain. While laboratory tests can determine whether the bacteria are present in the body or not, the diagnosis of rheumatic fever, at the time of Feinstein’s writing, had no set objective procedure; it relied on a series of clinical criteria. Feinstein (1967) considered these criteria to be “subjective” as they rely on the clinician’s interpretation of what s/he observes.
6 Dollar amounts have been converted to current (2015) Canadian dollars using the Bank of Canada’s data.
7 This three-year timeline (1964-1967) proved to be too tight, and the first class was later pushed back to the fall of 1969. There were five years between the Ontario Ministry of Education’s investment in the medical school and its first class.
8 The “problem-based” learning model was also developed and implemented at McMaster University in the late 1960s. For a discussion of this model, see Barrows 1996. Future research could examine the relationship between this curriculum for medical training and the later emergence of EBM at the same institution.
9 Initially twenty students enrolled in the first year of the McMaster medical program. These students were housed in temporary quarters while the complex was completed. The enrolment targets of sixty-four incoming students per year would be met once the proper facilities could be completed. The new facility would not open until 1971 due to delays in labour, and to union conflicts.
10 The EBMWG was a collegial initiative in CE&B, a group of researchers who shared an interest in the pedagogy of medical training and the use of evidence in medical practice.
11 In The Philosophy of Evidence-based Medicine, Jeremy Howick (2011) concludes that the methods of EBM do, in fact, provide valid knowledge upon which clinical practice can be based, with a few caveats (see chapters 10 and 11).
12 The name was later changed to The UK Cochrane Centre.
About this article
Cite this article
Hanemaayer, A. Evidence-Based Medicine: A Genealogy of the Dominant Science of Medical Education. J Med Humanit 37, 449–473 (2016). https://doi.org/10.1007/s10912-016-9398-0
- evidence-based medicine
- clinical judgment
- medical education