Evidence-Based Medicine needs clinical practice: reflections on its use in Brazilian Primary Health Care

Resumen

The Choosing Wisely campaign, launched in 2012, aimed to reduce low-value medical interventions through evidence dissemination. However, studies have shown reductions of less than 2% in unnecessary testing, raising questions about the foundational assumptions of evidence-based medicine. This essay argues that this limited impact stems from a conceptual misunderstanding: the assumption that scientific evidence can substitute for clinical reasoning, when it actually depends on such reasoning to acquire meaning and applicability. We contend that evidence-based medicine requires clinical practice as an epistemological foundation, and that the progressive erosion of traditional clinical skills—history-taking, physical examination, and probabilistic reasoning—undermines the possibility of genuinely evidence-based practice. This reflection is particularly relevant in Brazilian Primary Health Care, where essential care attributes depend on clinical competencies irreducible to mechanical protocol application. The essay discusses the implementation paradox, the disuse of fundamental clinical skills, diagnostic cascades, and the Brazilian context of high professional turnover and cultural heterogeneity. Conceptual frameworks such as quaternary prevention, tolerance of uncertainty, and patient-centered care offer pathways for reorientation. We conclude that efficient and equitable health systems depend on professionals capable of exercising qualified clinical judgment, and that evidence-based medicine needs clinical practice as much as clinical practice needs evidence.