Get access

Integrating evidence into clinical practice: an alternative to evidence-based approaches


  • Mark R. Tonelli MD MA

    1. Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Department of Medicine and, Department of Medical History and Ethics, University of Washington, Seattle, WA, USA
    Search for more papers by this author

Dr Mark R. Tonelli
University of Washington
Box 356522
1959 NE Pacific Street
Seattle, WA 98195-6522


Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient.