Evidence-Based Medicine: A Genealogy of the Dominant Science of Medical Education

Abstract

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.

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Acknowledgements

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.

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Endnotes

Endnotes

  • 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.

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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

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Keywords

  • evidence-based medicine
  • clinical judgment
  • uncertainty
  • medical education
  • genealogy