Seven alternatives to evidence based medicine


David Isaacs, clinical professor, Dominic Fitzgerald, staff physician.
Departments of Education and Medicine, New Children's Hospital, Westmead, NSW 2145, Australia

Clinical decisions should, as far as possible, be evidence based. So runs the current clinical dogma. We are urged to lump all the relevant randomised controlled trials into one giant meta-analysis and come out with a combined odds ratio for all decisions. Physicians, surgeons, nurses are doing it; soon even the lawyers will be using evidence based practice. But what if there is no evidence on which to base a clinical decision?

We, two humble clinicians ever ready for advice and guidance, asked our colleagues what they would do if faced with a clinical problem for which there are no randomised controlled trials and no good evidence. We found ourselves faced with several personality based opinions, as would be expected in a teaching hospital. The personalities transcend the disciplines, with the exception of surgery, in which discipline transcends personality. We categorised their replies, on the basis of no evidence whatsoever, as follows.

  1. Eminence based medicine
    The more senior the colleague, the less importance he or she placed on the need for anything as mundane as evidence. Experience, it seems, is worth any amount of evidence. These colleagues have a touching faith in clinical experience, which has been defined as "making the same mistakes with increasing confidence over an impressive number of years."7 The eminent physician's white hair and balding pate are called the "halo" effect.
  2. Vehemence based medicine
    The substitution of volume for evidence is an effective technique for brow beating your more timorous colleagues and for convincing relatives of your ability.
  3. Eloquence based medicine
    The year round suntan, carnation in the button hole, silk tie, Armani suit, and tongue should all be equally smooth. Sartorial elegance and verbal eloquence are powerful substitutes for evidence.
  4. Providence based medicine
    If the caring practitioner has no idea of what to do next, the decision may be best left in the hands of the Almighty. Too many clinicians, unfortunately, are unable to resist giving God a hand with the decision making.
  5. Diffidence based medicine
    Some doctors see a problem and look for an answer. Others merely see a problem. The diffident doctor may do nothing from a sense of despair. This, of course, may be better than doing something merely because it hurts the doctor's pride to do nothing.
  6. Nervousness based medicine
    Fear of litigation is a powerful stimulus to overinvestigation and overtreatment. In an atmosphere of litigation phobia, the only bad test is the test you didn't think of ordering.
  7. Confidence based medicine
    This is restricted to surgeons (table).
Basis of clinical practice
Basis for clinical decisions Marker Measuring device Unit of measurement
Evidence Randomised controlled trial Meta-analysis Odds ratio
Eminence Radiance of white hair Luminometer Optical density
Vehemence Level of stridency Audiometer Decibels
(or elegance)
Smoothness of tongue or nap of suit Teflometer Adhesion score
Providence Level of religious fervour Sextant to measure angle of genuflection International units of piety
Diffidence Level of gloom Nihilometer Sighs
Nervousness Litigation phobia level Every conceivable test Bank balance
Confidence * Bravado Sweat test No sweat
* Applies only to surgeons.

There are plenty of alternatives for the practising physician in the absence of evidence. This is what makes medicine an art as well as a science.