Tonelli Mark R
Division of Pulmonary and Critical Care Medicine, Department of Medicine and, Department of Medical History and Ethics, University of Washington, Seattle, WA 98195-6522, USA.
J Eval Clin Pract. 2006 Jun;12(3):248-56. doi: 10.1111/j.1365-2753.2004.00551.x.
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.
循证医学（EBM）至今未能充分考虑如何将医疗决策的其他潜在依据合理纳入临床实践。特别是，循证医学在整合其他类型的医学知识（如源自临床经验或基于病理生理原理的知识）及其价值方面一直存在困难。在所有循证医学方法中，普遍优先考虑临床研究得出的经验证据，这在认知上是站不住脚的。一种与循证医学方法不同的决疑法认识到，五个不同的主题，即1）经验证据、2）体验证据、3）病理生理原理、4）患者目标和价值观以及5）系统特征，可能与任何临床决策相关。没有一个主题普遍优先于其他主题，某个主题的相对重要性将取决于具体病例的情况。熟练的临床医生必须权衡这些可能相互冲突的行动依据（包括证据性和非证据性的），运用实践推理和理论推理，以便为个体患者做出最佳选择。
