What do you propose?

If Evidence-Based Medicine is as flawed and problematic as I’ve argued, then what do I propose?  What does this mean for Medicine and clinical research going forward?  If not EBM, then what? 

Well, to start one could consider opening up the spectrum of acceptable evidence to include qualitative evidence. Instead of trying to quantify someone’s quality of life or severity of incontinence with a numerical tool, we could consider discussing these issues in qualitative, narrative terms.  We could open up and legitimize expert opinion and experience.  We can consider creative and alternate approaches to investigating various medical interventions. Instead of trying to make everything into a randomized clinical trial, we could realize when such attempts are futile and a waste of time and money. If you were trying to assess, for example, what the effect of chemotherapy is on a patients cognitive function, you could talk to patients, to their families, to their physicians and nurses. Ask for opinions, not numerical scores. One could acknowledge the inherent subjectivity of these issues. Instead of seeing subjectivity as the enemy, one could recognize it for its strength. One could drop the facade of blindness and randomization in certain studies, where it is clear that randomization and blindness are impractical and unrealistic. It will be hard work, but the results might be quite valuable. 

If interested whether a given chemotherapeutic agent or a regimen of therapeutic agents  is better, for example,  one could consider actually asking the investigators their opinion and experiences. The patient’s too for that matter.   One could even consider dropping the facade of blindedness and randomization in certain studies. Instead of treating bias as the enemy, one could even embrace it. I know these ideas run completely counter to the generally accepted doctrines of modern clinical research.  But we might be surprised by what they reveal.