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The past decade has seen a massive drive towards health care reform. The agenda has involved a number of initiatives including managed care, co-ordinated care, purchaser provider models, quality improvement initiatives, and cost rationalization models. This paper explores the dynamics around a significant initiative in health care reform - evidence-based practice (EBP). One cannot work in health care without in some way interacting with the notion of EBP. In this paper I argue that events in the broader domain have shaped the direction of the health reform agenda, distorting its focus, balance, and priorities and creating circumstances in which dominant paradigms act as social defences (Jaques, 1955; Menzies Lyth, 1959) against thinking, creativity, and best practice. EBP has become a phenomenon in health care, transcending its definition. This impacts on the way it has been operationalized to inform decision-making in health care. Indeed, the title of my paper, ‘You're either with us or against us’ has been coined to suggest that EBP has become politicized and idealized to become the dominant discourse in health care, rendering other discourses as marginal and diminishing EBP's capacity to enhance effective clinical practice.
Evidence-based approaches to health care decision-making are underpinned by tools developed through epidemiology - in particular the reliance on randomized control trials and systematic reviews, and