Detailed guides to painful problems, treatments & more

EBM versus clinical experience

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

The application of evidence-based medicine (EBM) has always involved a mixture of evidence, experience, and the particulars of each case. For instance, a physical therapist deciding whether or not to use dry needling might consider three things:

There’s several variations on this chart, but the take-home message is always the same: the application of EBM isn’t just about the evidence.

  1. the evidence supporting dry needling is a bit iffy,
  2. but in his experience it works well for most people,
  3. and yet this patient reacts very poorly to it and doesn’t care for the risk, even if there’s still a possibility of benefit.

In other words, EBM isn’t exclusively about the evidence. It’s based on it, but not limited to it. And so I got this savvy question recently:

You are obviously keen on being known as an EBM-friendly website, so what do you do when the evidence is contradicted by the clinical experience of your readers? Or your own?

The artful merging of evidence and experience with the unique special-flowerness of the patient in front of you is a clinical challenge … not a writing challenge. Clinicians have to make decisions based on all three, every day. That’s their job. I left that challenge behind several years ago. These days, my new challenge is to provide clinicians (and patients) with as good a picture of the evidence as I can. I’m a specialist now — I focus on just one of the pillars of EBM, the science-y pillar.

On the other hand, I was also a clinician for ten years, and I have constant and deep correspondence with many extremely experienced clinicians today. So there are hat tips to clinical experience here there and everywhere on Certainly I do talk about what clinicians believe. But, mostly, I stick to what the evidence can support.

But for you clinicians: when confronted with evidence that’s a bummer, at odds with your experience, remember that your experience is a fully legit third of that EBM‬ equation. But! You must be very cautious not to lean too hard on your experience, because “you are the easiest person to fool” (Feynman). It’s only a third of the equation. Not two thirds. Not half. Just a third, roughly, give or take (probably always less than a third for younger professionals). And it’s never a very reliable third. Just like science, experience is difficult to interpret and often wrong.