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In 1992, the Evidence-Based Medicine Working Group issued a clarion call to physicians to focus away from intuition, unsystematic clinical experience, and pathophysiological rationale as grounds for clinical decisions. They recommended, instead, that we base patient care on evidence from clinical research, that is, on our review of published literature (EBM Working Group, 1992). It ranked clinical evidence in a hierarchy based on the design of the study, from single case reports up through double blind randomized clinical trials (RCT), without regard to the quality of the research. An early training film showed a medicine resident telling a patient the results of some laboratory tests, then leaving the examining room to do a computer search, then returning to give the patient a prescription. In this scenario, the patient seems to make no contribution to the discussion, either as participant or as a person.
Criticism came rapidly from various sectors of medicine. Dynamic psychiatrists wondered whether this was a new paradigm or a new cognitive disorder. Others noted that this sort of medicine relies on imperfect methodology and a science base that is currently incomplete (Phelps, 1993); it addresses single aspects of a complex patient; it devalues clinical intelligence (Tanenbaum, 1993); and it views the patient as an inconvenient container of a biomedical process. It serves policies that aim to control costs for populations by sacrificing efficient care over the lifetime of the individual (; Kassirer, 1993).