Throughout this website I have been reluctant to use the word “epistemology” when describing my endeavor. But it is clear to anyone familiar with philosophy that my discussion here is in part an inquiry into the epistemology of medical knowledge and how we know things in Medicine. As mentioned in the section Other Commentators, there is extensive literature devoted to examining and criticizing the philosophical foundations of EBM. The discussion here differs in that I am trying to get away from a “philosophical” or “theoretical” discussion of EBM. Not because I think these are wrong or misguided. Indeed, I think many of them are deeply insightful and compelling. But because I do not believe that people are generally convinced by argument or theory. I do not think that the EBM establishment will just toss in the towel, if I (or anyone) were to show that there are vast philosophical inconsistencies in the epistemology of EBM.
Nor, for that matter, do I believe that people are generally convinced by evidence. Even if we had great “evidence” supporting the view that EBM leads to worse patient outcomes, I doubt very much that anyone would be convinced by it. One of the questions I posed on the Take the Test page of this website recognizes this phenomena:
18. Do you ever feel that arguing about evidence is futile, that we frequently just use evidence to justify our beliefs and discount it when it does not suit our purposes?
I do not think we are irrational because we use evidence to support our beliefs and discount it when it goes against them. The complexity of human belief and decision-making remains, in large part, a mystery. But David Hume’s contention that “reason is and ought only to be a slave of the passions” contains a piercing insight about the nature of human belief and our motivation to act. Whether Hume was entirely right does not really matter. There is clearly a complex interplay between facts, experience, personal belief and a number of other factors. How we come to believe things or change our beliefs will never lend itself to complete understanding. Nor will it lend itself to algorthmic simplification.
But this does not mean we are incapable of changing our views or ideas. While numerical evidence may not have as profound an impact on our views as we sometimes think, I do believe that we are influenced by compelling narratives…by narratives which speak to our own experience and knowledge… and which help to make sense of the blooming buzzing confusion of our lives. In fact, I think the rise of the term “Narrative” in modern discourse is a recognition in large part that we are not often convinced by evidence. But rather, we are convinced by a compelling story that helps makes sense of our experiences.
I think that most practicing physicians have an intuitive sense that something is not quite right with EBM and its approach to medical practice. But they are either too busy or unable to articulate what it is they sense or they are wary of being contrary to the medical establishment. My goal in this website is to tell a story, a narrative about the short-comings of EBM and to appeal to the reservations many physicians have about it. My goal here is to help us understand why EBM doesn’t work so that we can better understand what can work.