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.