Evidence-based medicine-the decline of authoritarian medicine

Evidence-based medicine according to a British Medical Journal, 'Remains a hot topic for clinicians, public health practitioners, purchasers, planners and the public...and has become a common topic in the lay media'. An understanding of evidence-based medicine requires first of all an appreciation of classical medical practice, because evidence-based medicine represents a clear shift, in focus and orientation for student, teacher and practitioner of medicine alike. The classical medical practice paradigm according to an editorial in the Postgraduate Medical Journal requires doctors to identify the problem, use their experience, ask a trusted colleague, consult a reference text, or read a review. The same journal, says that the evidence-based approach - the new paradigm - requires doctors to formulate an appropriate clinical question, conduct a literature search, select the key articles, critically appraise the articles, and then apply the results of the search to the patient. This new emphasis on the use of medical literature in the provision of care is considered to be so fundamental as to constitute a paradigm shift. The evidence-based approach de-emphasizes intuition, and puts a much lower value on authority but does not reject it, since it recognizes that there are exceptional clinicians who have a gift for intuitive diagnosis and precise observation. It asserts, however, that systematic recording of observations in a reproducible and unbiased fashion will increase the confidence levels about knowledge of diagnosis, prognosis and efficacy of treatment, and further that an understanding of disease and physiological processes, while important, is insufficient as a guide for clinical practice (AU)

Ways of knowing about birth in three cultures

This article examines the concept of authoritative knowledge elaborated by Brigitte Jordan, using examples of birthing systems in Mexico, Texas, and Jamaica. We explore the linkages between the distribution of knowledge about birth and the use of technology; the valuation of biomedical and alternative ways of knowing about birth; the production of authoritative knowledge through interaction; and the relationship between authoritative knowledge and social status. In the Maya low-technology, collaborative birthing system in Mexico, the midwife and other adult women share knowledge about birth. In contrast, Spanish-speaking women undergoing cesarean delivery in a high-technology public hospital in Texas are, due to their limited English, only minimally able to interact with hospital staff. While they acknowledge the authoritative position of biomedical personnel and value technology, they protest their inability to communicate during their hopitalization. Jamaican women deliver in a formerly high-technology hospital system that is now experiencing economic austerity measures that render it increasingly dysfunctional. While use of technology is infrequent in the Jamaican case, authoritative knowledge remains vested in biomedicine. By means of three examples we respond to Jordan's call for rethinking of authoritative knowledge in high- and low-technology settings. (AU)