The evidence-based medicine movement has remained both well known and controversial since its inception. The authors reframe the evidence-based medicine debate by pointing out an underappreciated epistemological deficiency: evidence-based medicine as currently conceptualized cannot accommodate concepts that resist quantitative analysis and therefore cannot logically differentiate human beings from complex machines. The authors use Michael Polanyi's philosophy of tacit knowing (which refers to the taken-for-granted knowledge at the periphery ofattention that allows persons to understand the world and discern meaning in it) as a starting point for rectifying this deficiency and for working towards an improved, person-centered epistemology of medical practice. The authors demonstrate that not only evidence-based medicine but also most traditional theories of medical practice need a concept such as tacit knowing to account for the kinds of knowledge human beings actually use. Polanyi's philosophy of tacit knowing is defined and briefly explained. A medical epistemology that can account for the tacit dimension of human knowledge and recognize physicians and patients as persons requires a revised conception of medical uncertainty and a recognition that clinician–patient interactions are central to medicine. The authors discuss practical implications of tacit knowing for medical practice, education, research, and health care policy and suggest ways for moving beyond evidence-based medicine towards a comprehensive epistemology of medical practice.
Dr. Henry is an intern, University of Michigan Health System, Department of Internal Medicine, Ann Arbor, Michigan.
Dr. Zaner is Ann Geddes Stahlman Professor Emeritus of Medical Ethics and Philosophy of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
Dr. Dittus is Albert and Bernard Werthan Professor of Medicine; chief, Division of General Internal Medicine and Public Health; director, Institute for Medicine and Public Health; Vanderbilt University Medical Center; and director, Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee.
Correspondence should be addressed to Dr. Henry, Internal Medicine Residency Program, 3116 G Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0368; telephone: (734) 545-0989; fax: (734) 936-3654; e-mail: (email@example.com).