In Search of Evidence

Chapter 2
Abstract
Evidence-based practice is all around us. Not only has medicine embraced its principles,
but so have education, social welfare, criminal justice and, last but not least,
management. With only slight exaggeration, Evidence-based practice can be said to be
emblematic of the modern professional. This chapter addresses the implications of this
trend toward evidence-based practice, by taking a close look at its first introduction, in
medicine. Given evidence-based medicine’s almost paradigmatic status, we then will
cover the similarities and the differences between the two professional fields. In doing
so, we will show that the hindrances that block the further development of evidencebased
management today are the same hindrances that blocked the development of
evidence-based medicine two decades ago.
The Rise of Evidence-Based Medicine
As a concept, “evidence-based medicine” was coined in the 1990s. It was defined
as “the conscientious, explicit and judicious use of current best evidence in making
decisions about the care of individual patients” (Sackett, Rosenberg, Gray, Haynes, &
Richardson, 1996). This definition is striking, because it implies that the practice of
medicine was not always “conscientious, explicit, and judicious.” In the 1960s and
1970s, people like Alvan Feinstein, Archie Cochrane, and Henrik Wulff –generally
considered as the pioneers of the evidence-based medicine movement–were struck by
the fact that clinical practice was characterized by much diversity. In clinical decisionmaking,
experience, intuition, and the wisdom of former teachers seemed to be more
important than scientific first principles. Feinstein, Cochrane, and Wulff found this
intellectually disturbing, and tried to remedy this situation by writing books that
became classics to the movement: Clinical Judgment by Feinstein (Feinstein, 1967),
Effectiveness and Efficiency by Cochrane (Cochrane, 1972) and Rational Diagnosis and
Treatment by Wulff (Wulff, 1976). Parallel to this self-reflection by physicians, there
was growing criticism on medicine and physicians from outside medicine. Physicians
were accused of being inconsistent in diagnosis and treatment, causing iatrogenic
damage, and for being responsible for a cost explosion in health care. This situation
was especially disturbing because the average life expectancy at birth had remained
much the same during the second half of the twentieth century.
An evaluation of the effectiveness and efficiency of health care was called for, and
this is exactly what happened. A new discipline was created: clinical epidemiology.
Epidemiology, a branch of medical science dealing with factors affecting the health
and illness of large populations, had existed for many years, but it was associated with