Originally published in an
ACP Journal Club in 1996 with text by EBM Apostle David Sackett as above, this perplexing figure has happily survived into recent collaborative work between omnipresent EBM Apologists Haynes, Devereaux and Guyatt[1]. While no
explicit mention is made of Jacques Lacan, I think it's obvious that we're facing a vast conspiracy and a shadow war not fought in journals but in signs. Either Lacanians are infiltrating the rank and file of the EBM movement in an attempt to make up lost ground in Anglophonia or EBM is attempting to assimilate Lacanian topological mathemes in a bid for the unconsciousness of psychoanalysts. (The facile objection that "It's only a Venn diagram!" can be immediately dismissed. "It's only a book!" cried the miner, dropping
The Conditions of the Working Class in England in the mud as the Pinkerton broke his jaw.) While my methods permit me to detect this correlation between crypto-Lacanian and crypto-epidemiological interests, sadly I have no answer to the vexing question of which is the cause of which or if their constant conjunction has been brought about
by some common origin, or even if my categories have referents. All I know is what's right in front of our collective nose.
It seems intuitively obvious that Clinical Expertise is the realm of the Imaginary, Research Evidence the Real and Patient Preferences the Symbolic. (Does the Other have a
preference? Only since the 90s, comrades.) That the center of the knot is the
objet petit a will come as no surprise to the physician, who knows well that what he desires is for the clinic, the patient and the evidence to appear together. Alas, it is not to be.
In the sequel, I hope to deal with the vexing issue of the diagram's reconfiguration in 2002, as the possibility of attaining clinical expertise fades and the subject of EBM becomes ever more clearly the effect of the desire of medicine and not its condition, clinical expertise as the
sinthome or
synth-homme appears, vanishingly, as the way that research evidence enjoys the unconscious.
[1] Haynes, R. B., Devereaux, P. J., & Guyatt, G. H. (2002). Physicians’ and patients’ choices in evidence based practice. BMJ, 324, 1350.
