Pragmatic medicine, n=1

Many practising clinicians have voiced concerns about limitations and imperfections associated with evidence-based medicine. Some of those concerns are aimed at the methodology and objectives of present-day medical research; others are a reflection of diverse environments and populations in which medical care is delivered. We argue in this paper that absence of evidence for any particular approach does not equate with evidence of absence of benefit of a considered intervention. Sufficient rather than perfect solutions may reflect patient preference or contextual constraints rather than ignorance on the part of the clinical practitioner. Relying on evidence without applying clinical judgement may sometimes be inappropriate. Medicine that acknowledges gaps in evidence needs to be pragmatic, seeking a solution for the patient in front of us.