Theoretical Medicine and Bioethics

, Volume 30, Issue 3, pp 181–198 | Cite as

Clinical intuition versus statistics: different modes of tacit knowledge in clinical epidemiology and evidence-based medicine

  • Hillel D. BraudeEmail author


Despite its phenomenal success since its inception in the early nineteen-nineties, the evidence-based medicine movement has not succeeded in shaking off an epistemological critique derived from the experiential or tacit dimensions of clinical reasoning about particular individuals. This critique claims that the evidence-based medicine model does not take account of tacit knowing as developed by the philosopher Michael Polanyi. However, the epistemology of evidence-based medicine is premised on the elimination of the tacit dimension from clinical judgment. This is demonstrated through analyzing the dichotomy between clinical and statistical intuition in evidence-based medicine’s epistemology of clinical reasoning. I argue that clinical epidemiology presents a more nuanced epistemological model for the application of statistical epidemiology to the clinical context. Polanyi’s theory of tacit knowing is compatible with the model of clinical reasoning associated with clinical epidemiology, but not evidence-based medicine.


Clinical reasoning Clinical epidemiology Evidence-based medicine Epistemology Intuition Randomization Statistics Tacit knowing 


  1. 1.
    Polychronis, A., A. Miles, and P. Bentley. 1996. Evidence-based medicine: Reference? Dogma? Neologism? New orthodoxy? Journal of Evaluation in Clinical Practice 2 (1): 1–3.Google Scholar
  2. 2.
    Feinstein, A.R., and R. Horwitz. 1997. Problems in the ‘evidence’ of ‘evidence-based medicine’. American Journal of Medicine 103 (6): 529–535.CrossRefGoogle Scholar
  3. 3.
    Malterud, K. 2002. Reflexivity and metapositions: Strategies for appraisal of clinical evidence. Journal of Evaluation in Clinical Practice 8 (2): 121–126.CrossRefGoogle Scholar
  4. 4.
    Henry, S. 2006. Recognizing tacit knowledge in medical epistemology. Theoretical Medicine and Bioethics 27 (3): 187–213.CrossRefGoogle Scholar
  5. 5.
    Polanyi, M. 1974. Personal knowledge: Towards a post-critical philosophy. Chicago: University of Chicago Press.Google Scholar
  6. 6.
    Polanyi, M. 1997. Creative imagination. In In society, economics & philosophy: Selected papers of Michael Polanyi, ed. R.T. Allen, 249–266. New Brunswick: Transaction Publishers.Google Scholar
  7. 7.
    Polanyi, M. 1946. Science, faith and society. London: Oxford University Press.Google Scholar
  8. 8.
    Thornton, T. 2006. Tacit knowledge as the unifying factor in evidence-based medicine and clinical judgment. Philosophy, Ethics, and Humanities in Medicine 1 (2). Accessed 25 Mar 2009.
  9. 9.
    Smith, D.G. 2008. Viewpoint: Envisioning the successful integration of EBM and humanism in the clinical encounter: Fantasy or fallacy. Academic Medicine 83 (3): 268–273.CrossRefGoogle Scholar
  10. 10.
    Sackett, D.L., W. Scott Richardson, W. Rosenberg, and R. Brian Haynes. 1997. Evidence-based medicine: How to practice and teach EBM. Churchill: Livingstone.Google Scholar
  11. 11.
    Guyatt, G., and D. Rennie. 2002. The philosophy of evidence-based medicine. User’s guide to the medical literature: A manual for evidence-based clinical practice. Chicago: AMA Press.Google Scholar
  12. 12.
    Sackett, D.L., R.B. Haynes, G.H. Guyatt, and P. Tugwell. 1991. Clinical epidemiology: A basic science for clinical medicine. Boston: Little Brown.Google Scholar
  13. 13.
    Medawar, P.B. 1969. Induction and intuition in scientific thought. Philadelphia: American Philosophical Society.Google Scholar
  14. 14.
    Elstein, A.S. 2000. Clinical problem solving and decision psychology. Academic Medicine 75 (10 Supplement): S134–S136.Google Scholar
  15. 15.
    Fisher, R. 1926. The arrangement of field experiments. Journal of the Ministry of Agriculture of Great Britain 33: 503–513.Google Scholar
  16. 16.
    Fisher, R. 1951/1935. The design of experiments. Edinburgh: Oliver and Boyd.Google Scholar
  17. 17.
    Hill, A.B. 1951. The clinical trial. British Medical Bulletin 7: 27882.Google Scholar
  18. 18.
    Hill, A.B. 1952. The clinical trial. New England Journal of Medicine 247: 113–119.Google Scholar
  19. 19.
    Hill, A.B. 1990. Memories of the British streptomycin trial in tuberculosis: The first randomized clinical trial. Controlled Clinical Trials 11: 77–79.CrossRefGoogle Scholar
  20. 20.
    Horton, R. 2000. Common sense and figures: The rhetoric of validity in medicine. Statistics in Medicine 19: 3149–3164.CrossRefGoogle Scholar
  21. 21.
    Hill, A.B. 1971. Principles of medical statistics. New York: Oxford University Press.Google Scholar
  22. 22.
    Marks, H.M. 2003. Rigorous uncertainty: Why R.A. Fisher is important. International Journal of Epidemiology 32: 932–937.CrossRefGoogle Scholar
  23. 23.
    Sleigh, J.W. 1997. Logical limits of randomized controlled trials. Journal of Evaluation in Clinical Practice 3 (2): 145–148.CrossRefGoogle Scholar
  24. 24.
    Kaptchuk, T. 2001. The double-blind, randomized, placebo-controlled trial: Gold standard or golden calf? Journal of Clinical Epidemiology 54: 541–549.CrossRefGoogle Scholar
  25. 25.
    Altman, D.G. 2000. Statistics in medical journals: Some recent trends. Statistics in Medicine 19: 3281–3284.Google Scholar
  26. 26.
    Grossman, J., and F. Mackenzie. 2005. The randomized controlled trial: Gold standard, or merely standard? Perspectives in Biology and Medicine 48 (4): 516–534.CrossRefGoogle Scholar
  27. 27.
    Davidoff, E. 1999. In the teeth of the evidence: The curious use of evidence-based medicine. Mount Sinai Journal of Medicine 66 (2): 75–83.Google Scholar
  28. 28.
    Guyatt, G.H., D. Sackett, D.W. Taylor, J. Chong, R. Roberts, and S. Pugsley. 1986. Determining optimal therapy: Randomized trials in individual patients. New England Journal of Medicine 314 (14): 889–892.CrossRefGoogle Scholar
  29. 29.
    Paul, J. 1938. Clinical epidemiology. Journal of Clinical Investigation 17: 539.CrossRefGoogle Scholar
  30. 30.
    Daly, J. 2005. Evidence-based medicine and the search for a science of clinical care. Berkeley: University of California Press.Google Scholar
  31. 31.
    Feinstein, A.R. 1973. An analysis of diagnostic reasoning: II. The strategy of intermediate decisions. Yale Journal of Biology and Medicine 46: 264–283.Google Scholar
  32. 32.
    Evidence.Based.Medicine.Working. Group. 1992. Evidence based medicine: A new approach to the teaching of medicine. JAMA 268: 2420–2425.CrossRefGoogle Scholar
  33. 33.
    Feinstein, A.R. 1967. Clinical judgment. Baltimore, Maryland: Williams Wilkins.Google Scholar
  34. 34.
    Feinstein, A.R. 1963. The basic elements of clinical science. Journal of Chronic Diseases 16: 1125–1133.CrossRefGoogle Scholar
  35. 35.
    Feinstein, A.R. 1964. Scientific methodology in clinical medicine: I–III. Annals of Internal Medicine 61 (3, 4, 6): 564–579, 757–781, 1162–1193.Google Scholar
  36. 36.
    Feinstein, A.R. 1968. Clinical epidemiology: I–III. Annals of Internal Medicine 69 (4, 5, 6): 807–820, 1037–1061, 1287–1311.Google Scholar
  37. 37.
    Feinstein, A.R. 1977. Clinical biostatistics. C.V. Mosby: Saint Louis.Google Scholar
  38. 38.
    Feinstein, A.R. 1983. An additional basic science for clinical medicine. Pts. I–III. Annals of Internal Medicine 99: 393–397, 544–550, 705–712.Google Scholar
  39. 39.
    Feinstein, A.R. 1985. Clinical epidemiology: The architecture of clinical research. Philadelphia: W.B. Saunders Company.Google Scholar
  40. 40.
    Feinstein, A.R. 1987. Clinimetrics. New Haven: Yale University Press.Google Scholar
  41. 41.
    Foucault, M. 1973. The birth of the clinic. New York: Vintage Books.Google Scholar
  42. 42.
    Gill, J.H. 2000. Michael Polanyi’s postmodern philosophy. Albany: State University of New York Press.Google Scholar
  43. 43.
    Wilczak, P.F. 1973. Faith, motive, and community: An interpretation of the philosophy of Michael Polanyi. Ph.D. thesis. Divinity School, University of Chicago.Google Scholar
  44. 44.
    Henry, S.G., R.M. Zaner, and R.S. Dittu. 2007. Viewpoint: Moving beyond evidence-based medicine. Academic Medicine 82 (3): 292–297.CrossRefGoogle Scholar
  45. 45.
    Cassell, E. 1985. Talking with patients. Volume 1. The theory of doctor-patient communication. Cambridge: MIT Press.Google Scholar
  46. 46.
    Wilensky, U. 1997. What is normal anyway? Therapy for epistemological anxiety. Educational Studies in Mathematics 33 (2): 171–202.CrossRefGoogle Scholar
  47. 47.
    Kahneman, D., and A. Tversky. 1974. Judgment under uncertainty: Heuristics and biases. Science 185: 1124–1131.CrossRefGoogle Scholar

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© Springer Science+Business Media B.V. 2009

Authors and Affiliations

  1. 1.Biomedical Ethics UnitMcGill UniversityMontrealCanada

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