Science and proven experience: a Swedish variety of evidence based medicine and a way to better risk analysis?

A key question for evidence-based medicine (EBM) is how best to model the
way in which EBM should ‘[integrate] individual clinical expertise and the best
external evidence’. We argue that the formulations and models available in
the literature today are modest variations on a common theme and face very
similar problems when it comes to risk analysis, which is here understood
as a decision procedure comprising a factual assessment of risk, the risk
assessment, and the decision what to do based on this assessment, the risk
management. Both the early and updated models of evidence-based clinical
decisions presented in the writings of Haynes, Devereaux and Guyatt assume
that EBM consists of, among other things, evidence from clinical research
together with information about patients’ values and clinical expertise. On
this A-view, EBM describes all that goes on in a specific justifiable medical
decision. There is, however, an alternative interpretation of EBM, the B-view,
in which EBM describes just one component of the decision situation (a
component usually based on evidence from clinical research) and in which,
together with other types of evidence, EBM leads to a justifiable clincial
decision but does not describe the decision itself. This B-view is inspired
by a 100-years older version of EBM, a Swedish standard requiring medical
decision-making, professional risk-taking and practice to be in accordance
with ‘science and proven experience’ (VBE). In the paper, we outline how the
Swedish concept leads to an improved understanding of the way in which
scientific evidence and clinical experience can and cannot be integrated in
light of EBM. How scientific evidence and clinical experience is integrated
influences both the way we do risk assessment and risk management. In
addition, the paper sketches the as yet unexplored historical background
to VBE and EBM.