A broken paradigm? What education needs to learn from evidence-based medicine Lucinda McKnight & Andy Morgan.

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A broken paradigm? What education needs to
learn from evidence-based medicine
Lucinda McKnight & Andy Morgan
To cite this article: Lucinda McKnight & Andy Morgan (2019): A broken paradigm? What
education needs to learn from evidence-based medicine, Journal of Education Policy, DOI:
10.1080/02680939.2019.1578902
To link to this article: https://doi.org/10.1080/02680939.2019.1578902
Published online: 15 Feb 2019.
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A broken paradigm? What education needs to learn from
evidence-based medicine
Lucinda McKnight a
and Andy Morgan b
a
School of Education, Faculty of Arts and Education, Deakin University, Melbourne, Australia; b
School of
Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University,
Melbourne, Australia
ABSTRACT
The paradigm of evidence-based education continues to inform the
development of policy in a number of countries. At its simplest
level, evidence-based education incorporates evidence, often that
provided by randomised controlled trials, into classroom practice.
England’s Education Endowment Foundation is in the process of
exporting evidence-based school education, promoted as a medical
approach, to other countries, including Australia. Australia is in the
process of establishing an Education Evidence Base, informed by
the government’s 2016 Productivity Commission report. While the
literature around evidence-based education is explicit in identifying
its basis in medicine, there has been little medical input into its
development. Interdisciplinary examination of the medical literature
reveals the contested nature and troubled state of evidence-based
medicine and what policymakers need to consider to maximise the
benefits of this translation into education.
ARTICLE HISTORY
Received 22 June 2018
Accepted 1 February 2019
KEYWORDS
Evidence-based education;
epistemology; feminism;
diversity; medicine
Introduction: the origins of evidence-based practice
An evidence-based movement in education might be traced back to the Cochrane
Collaboration’s evidence-based medical initiatives in 1993 (Shahjahan 2011). This
movement includes a focus on behaviourist theory, quantitative research, randomised
controlled trials, meta-analyses, ‘hard’ numerical data and high stakes standardised
testing, as enacted by global advocates of the pervasive mantra of ‘what works’ (cri-
tiqued by Biesta 2007), the ‘No Child Left Behind’ Act (Bush 2001) in the USA and
‘Visible Learning’ (Hattie 2009), originating in the Antipodes. Despite unintended
negative effects (Darling-Hammond 2007) of these kinds of approaches, which ignore
structural inequalities in pursuit of better outcomes, positivist versions of evidence-
based education are increasingly dominating the field.
In medicine, evidence-based practice is said to have begun with William Sackett and
colleagues’ late 1980s exploration of the dissonance between two versions of science: 1)
objective measurement and 2) the artistry of clinical decision making (Greenhalgh 1999;
Govert, Hans, and Nijhof 2003). Yet both medicine, and more recently education, have
CONTACT Lucinda McKnight l.mcknight@deakin.edu.au Deakin University, 221 Burwood Highway, Burwood
3125, Australia
JOURNAL OF EDUCATION POLICY
https://doi.org/10.1080/02680939.2019.1578902
© 2019 Informa UK Limited, trading as Taylor & Francis Group

drifted away from medicine’s original desire to value both science and art, to a positivist
focus on rational inquiry that involves the separation of knower and knowledge and the
creation of truths external to human relationships, whether in the consulting room or
the classroom. Where Sackett expected clinicians to disagree and encouraged research-
ing the degree and contexts of this diversity, evidence-based medicine (EBM) at its
worst produces policy in the form of guidelines that are used as sticks with which to
beat clinicians into uniformity of practice (Howick 2014). This article is not a critique
of evidence-based practice per se, as doctors and teachers have always drawn on a range
of evidence to inform practice, but an opportunity for education policymakers to
connect with and learn from EBM, a movement potentially ‘in crisis’ (Greenhalgh,
Howick, and Maskrey 2014, 1). The article departs from widespread and ‘trenchant’
(Connolly, Keenan, and Urbanska 2018, 1) criticisms of evidence-based practice emer-
ging from the educational community, through its focus on the complexities of EBM.
As a doctor and teacher thinking and writing together, we particularly draw on the work
of Professor Trisha Greenhalgh of the University of Oxford’s Centre for Evidence-based
Medicine, and her provocative questioning of whether this form of practice is ‘real vs
rubbish’ (2015) or ‘broken’ (2015). While she has long recognised EBM’s ‘exciting oppor-
tunities for improving patient outcomes’ (Greenhalgh 2002, 395) she has been vocal in
warning about its misuse. We recognise that this may shock policymakers and educators
who idealise medicine and borrow its aura to cultivate guru status in educational leader-
ship (Eacott 2017). However, we believe that a more honest understanding of the ambiv-
alences and failures of EBM is essential for education and ask, as our guiding research
question, what education policymakers need to know about the contested nature of EBM.
Our approach is interdisciplinary in that we aim to be ‘advancing understanding. . .
in ways that would not have been thought possible through single disciplinary means’
(Mansilla and Gardner 2003, 3). In terms of interdisciplinary theory, we are united by
entangled logics of both ontology (seeking to reconceptualise teacher-subjects within
evidence-based frameworks) and accountability (for education policymakers to the
public); we are similarly ‘driven by an agonistic or antagonistic relation to existing
forms of disciplinary knowledge and practice’ (Barry, Born, and Weszkalnys 2008, 29)
in relation to the evidence-based discourse now dominant in education.
This article is not an examination of policy itself, or an exhaustive literature review of
EBM, but the critical identification of key documents from the medical literature that
should or could inform educational policy development around evidence. They are
selected on the basis of wishing to demonstrate a range of diverse views on medical
evidence-based practice beyond the assumption that it is a universal good; this puts to
work the advice that thinking critically about policy requires ‘diverse concepts and
theories’ (Ball 1993, 10). We also translate the issues raised by this literature into
specific questions for education policymakers to consider, instigate discussion around
reasons for the absence of educational engagement with medical literature, and provide
recommendations for further research.
Medical paradigms in education
Prior to engaging with the medical literature, we note that the use of medical paradigms
in education has been widely critiqued over decades. Medical and scientific approaches
2 L. MCKNIGHT AND A. MORGAN

to education have been critiqued for their: colonising force (Shahjahan 2011); negation
of diverse epistemologies (Watkins 1993), bullying tendencies (Sleeter and Stillman
2005; Carlson 2014); elision of ethics (Brantlinger 2009); gendered bias (Harding 1986;
Apple 1986; Lather 2004; Pierre and Adams 2004) and detrimental effects on educators
and education (Hammersley 1997; Eisner [1967] 2017, [2001] 2017; Biesta 2007). This
list is but a tiny portion of the carefully argued resistance to the medical in education.
Yet the attempted imposition and/or importation of medical ideology and practice is
extraordinarily resilient in the face of this critique and tends to ignore the history of
debate, preferring to cyclically re-invent itself as a ‘new paradigm’ (Davies et al. 2015,
515). Such new paradigms inevitably herald increased rigor, yet conveniently sidestep
the intellectual rigor that substantive engagement with the history of critique would
require. Advocates have similarly been motivated to ‘disguise the imperfections of
evidence-based medicine’ (Govert, Hans, and Nijhof 2003, 465).
Proponents of evidence-based education (EBE) also fail to engage with the medical
literature that could inform their initiatives. The Australian government’s Productivity
Commission (2016a), for example, states blandly in relation to research methods of
evidence-based medicine, that ‘such approaches are widely used in health research’ (17).
Neither this overview, nor the full report, acknowledge EBM as a highly contested
(Govert, Hans, and Nijhof 2003) and relatively recent paradigm, which has undergone
three distinct stages (Greenhalgh 2015) since Sackett and colleagues’ initial interven-
tions. It is to be deliberated whether this is ignorance or a conscious cover up.
The transformation of the policy and practice of Australian education is to be based
on the denial of the evidence to hand that evidence-based practice in medicine, while
potentially enormously beneficial, can also lead to substantial harms (Greenhalgh 2018;
Tonelli 1998). It has also evolved considerably since the positivist model that seems to
appeal to education policymakers. Astonishingly, educators do readily admit that there
is no evidence that evidence-based practice in education has any benefits (Burn and
Mutton 2015), yet this does not lead to any delay in implementation of a particular and,
as we will demonstrate, limited traditional medical-style agenda.
Aims and theoretical resources
We set out briefly here the central debates in EBM; we recognise that we are, in a sense,
playing the EBE movement at its own game, using medicine to bolster an argument. Yet
we seek to do this in an informed manner, based on expertise in both education and
medicine and following careful reading of the literature achieved in tandem with
interdisciplinary dialogue. We argue that this dialogue is essential so that EBE does
not repeat the mistakes of EBM, and avoids detrimental effects on the lives of teachers
and students, and the waste of public funds on flawed interventions. The absence of this
dialogue in Australia’s policy environment and the failure to recognise the problems
with EBM already constitute a level of disingenuity that requires explanation. The
promotion of one particular, dated, and ideologically loaded version of EBM, without
rationale for its choice, is similarly problematic.
In our discussion, we also draw on several theoretical frameworks to develop our
theories. We invoke Foucault (1972), and the concept that discourse puts particular
cultural politics and power relationships to work through discursive traces relying on
JOURNAL OF EDUCATION POLICY 3

a particular recourse to rationality. We think with Harding’s (1986) philosophical
perspectives on the ways science is gendered, and reliant on an androcentric, coercive
rationality. She writes that, in science:
the focus on quantitative measures, variable analysis, impersonal and excessively abstract
conceptual schemes is both a distinctly masculine tendency and one that serves to hide its
gendered character. (Harding 1986, 105)
This focus includes notions of ‘hard’ science and ‘rigor’ that are used to justify evidence
based practice across disciplines, setting up binaries pitting reason against intuition:
a key issue for EBM (Greenhalgh 2002) and potentially for education. We also think
with Hall’s (1997) notion of the fetish, of looking at something yet failing, or refusing to
actually see it, instead regarding something else entirely. In this instance, we argue
educators claim to be looking at medicine, but are really focusing on, and deploying, its
positivist discursive trappings as symbols of masculinist power.
In the spirit of moving beyond critique to strategically address the problems we
identify, we also include questions for education policymakers, that, while specific to
the Australian timeframe for implementation, have resonance across all countries
engaging with evidence-based practices in education.
Issues in evidence-based medicine and questions for education
policymakers
EBM, while having well defined benefits, also carries specific and important
limitations
EBM is understood by Australian education policymakers as a scientific endeavour
based on randomised controlled trials (RCTs). These are defined as studies:
‘in which a number of similar people are randomly assigned to two (or more) groups
to test a specific drug, treatment or other intervention. One group (the experimental
group) has the intervention being tested, the other (the comparison or control group)
has an alternative intervention, a dummy intervention (placebo) or no intervention at
all. . . Outcomes are measured at specific times and any difference in response between
the groups is assessed statistically.’ (NICE 2018)
This kind of research makes a particular knowledge claim representing a single school,
that of medical epidemiology, or population health (Tonelli 1998), thereby essentialising
science and relying on a problematic version of EBM (Greenhalgh 2015). This form of EBM
establishes knowledge hierarchies (Zuiderent-Jerak, Forland, and Macbeth 2012) and in its
strictest form, devalues intuition, clinical experience and physiological rationales, with the
result that ‘the complex nature of sound clinical judgement is not appreciated’ (Tonelli
1998, 1234). Using this form of EBM to effect change risks an overemphasis on ‘epidemio-
logical approaches’ (Grol 1997, 419) which are potentially co-opted for coercion, in contrast
to educational, behavioural or social interactionist models of achieving change.
There are other medical paradigms, such as narrative-based medicine (Launer 1999;
Elwyn and Gwyn 1999; Zaharias 2018) and patient-centred medicine (Levenstein et al.
1986) that are much more closely aligned with education, and are used as a ‘medium for
education’ (Greenhalgh and Hurwitz 1999, 49) within medicine. These paradigms,

however, and their research methodologies, involve the soft skills of listening, empathis-
ing, reflecting, connecting, sharing, and understanding social and cultural contexts; in
effect, these paradigms value the practitioner and patient ahead of the authority
invested in system or science. These skills that education is choosing to deny are
constructed as feminised and inferior: shaping a professional identity, under neoliber-
alism, necessitates this process (McKnight 2016).
This rejection of multiple ways of knowing, and negation of the ‘soft stuff’
(Greenhalgh 2015) such as tacit knowledge and practical intuition for the adulation
of hard science, echoes abuses described in the long history of feminist critique of
science. Masculinist epistemology has long had reason triumphing over ‘feminine’
nature (Shiva 1993, [1988] 2010) in a dualism stretching back to René Descartes and
the mind/body split. Harding (1986) has traced the androcentrism of science through
centuries, along with the gendered fear that emotion, subjectivity and the abstract (all
culturally inscribed as feminine) might overwhelm man[sic]kind. The maintenance of
hierarchies of knowledge has also been specifically identified as a contribution to the
perpetuation of European colonialism and the ‘imperial mission’ (Shahjahan 2011, 184)
of maintaining racial and cultural superiority over ‘natives’ perceived as wild and
irrational. Any narrow version of EBM, based primarily on RCTs and meta-analyses,
performs these fears, abuses and inequalities of power, positioning practitioners and
patients (students) in deficit.
Thankfully, EBM has now shifted to integrating non-evidentiary knowledge, or to
a broader understanding of what may be considered evidence, such as clinical expertise
and patient preferences (Tonelli 1998; Greenhalgh 2015). These alternative forms of
knowledge are now considered not just desirable, but ‘necessary’ (Tonelli 1998, 1235)
for the profession, raising the question of how this might apply to education.
Related questions for education policymakers
● How will education learn from the mistakes of post-Sackett, positivist EBM, which
devalued the clinician (teacher) and the wisdom and skills acquired through
practice?
● How will education honour patient (student) perspectives ignored in early EBM?
● How can EBE move beyond replicating EBM, to model how teachers, students,
parents and communities can lead in determining what kind of evidence matters?
● How will EBE seek to flatten Western/Northern knowledge hierarchies to achieve
better relationships with Indigenous communities and welcome leadership by
Indigenous elders in this area?
● For Australia, how is the way EBE is conceptualised conducive to reconciliation,
especially considering the historical harms white Western/Northern medicine has
visited on Australia’s Indigenous peoples?
● How can EBE, in an environment of resurgent social feminism, avoid the domina-
tion of soft knowledge and skills by hard science? How can it avoid accusations of
being dominated by colonialist and sexist epistemologies that do not value the
knowledges and experiences of students?
● How can educators develop sophisticated, insightful and education-led ways of
integrating different evidence in practice?

● How can EBE support teachers in deciding when different forms of knowledge,
such as experiential, emotional and opinion and value-based knowledges (Tonelli
1998), should take precedence in their decision-making?
EBM changes the nature of medicine
There is no doubt that EBM can save lives, for example by being able to demonstrate
when whole-population screening is effective. However, in some forms of EBM, ‘the
individuality of patients tends to be devalued [and] the focus of clinical practice is
subtly shifted away from the care of individuals toward the care of populations’ (Tonelli
1998, 1234). Breast screening for cancer is an excellent example of this, with regular
mammography saving some lives, while harming many individuals who test positive,
but may never have needed the invasive treatment they subsequently receive (Marmot
et al. 2013). Breast cancer screening has become highly controversial for women at low
risk.
The application of EBM, in the form of using guidelines based on RCTs, has been
shown to inhibit individual patient care (Greenhalgh 2015, 2018). For example, a doctor
who follows the population-based guideline for a hypothetical patient, Mr Zhu, that
states he should be on a statin to prevent heart disease does not consider Mr Zhu’s
preference not to take medication or be medicalised. Recommending that he takes the
statin negates the patient’s deeply held values and compromises the interpersonal
doctor/patient relationship. When benchmarking is applied to this situation, with
financial rewards for doctors who comply, the situation becomes even more ethically
fraught.
Greenhalgh (2015), citing Bowker and Star, says, that in EBM:
we create classification schemes. Once these become enshrined in guidelines, protocols etc.
they ossify and reproduce our assumptions and prejudices (which now appear scientific).
EBM, with its population emphasis, makes individuals and their needs harder to
perceive, and to respect. Education has also identified the dangers of evidence-based
authority dominating in and ossifying in systems (Eacott 2017). This is particularly
noted in relation to the work of evidence-based academic Professor John Hattie (2009)
whose influential treatise on Visible Learning, based on a meta-meta analysis of 800
meta-analyses of effective learning has also attracted critique of its bullying power in
relation to teachers (McKnight and Whitburn 2018). The formalising and normalising
of guidelines based solely on quantitative research are problematic for both medicine
and education.
As a result of EBM’s capacity to undermine individual care, clinicians are now being
advised to use evidence more appropriately (Greenhalgh 2015), to tackle its ‘overall
reductionism’ (Fava 2017, 3). EBM carries the danger that truths from RCTs will be
‘mechanistically applied’ to patients whose behaviour is ‘irredeemably contextual and
idiosyncratic’ (Greenhalgh 1999, 324). A recent overview of RCTs conducted in educa-
tion since 1980 has revealed that process evaluations, which may suggest contextual
complications, are used only in a minority of trials (Connolly, Keenan, and Urbanska
2018, 13). This increases the risk that ‘what works’ may be applied to students without
understanding how circumstances may alter their needs.

EBM is also said to standardise the patient, and the moral considerations made in the
consultation (Govert, Hans, and Nijhof 2003) due to the distance created between
clinician and guideline, such that diverse patients, including those with comorbidities
(multiple medical problems), are assumed to conform to a simplistic ideal and treated
accordingly. Reasoning from the particular (starting with the patient) to the general,
becomes reasoning from the general (guideline) to the particular. This is a fundamental
philosophical change that readily becomes ‘advanced rule following’ (Greenhalgh 2018,
6) instead of case-based reasoning. The pursuit of ‘rigor’ all too easily becomes rigidity
(Govert, Hans, and Nijhof 2003) for those who practice ‘cookbook medicine’ (Tonelli
1998, 1239). Such imperatives pose a clear threat to teacher autonomy, and allow for the
standardization of teachers’ work, an ongoing project (Lindstrom 2018) that benefits
governments and corporate entities, but not necessarily teachers and students.
As an antidote, EBM has now begun to ‘seek patient-based evidence from unfolding
clinical conversations’ (Greenhalgh 2018, 6). Ironically, this is just as teachers are being
told that RCTs and meta-analyses must come first to inform practice, rather than, for
example, classroom action research involving conversations with students or educa-
tion’s rich history of narrative inquiry, case study and ethnography.
Questions for education policymakers
● How will EBE foreground and address the central philosophical tension between
benefits to populations and benefits to individuals inherent to evidence-based
practice?
● How will EBE protect students from the harms of standardization and the
mechanistic application of guidelines?
● How will EBE support teachers to fight the ‘pressure to adhere’ (Greenhalgh 2018,
2) that the purported rigor of RCT-based guidelines effects?
● How will EBE respect diversity when we know prejudices inhere within guidelines?
● How will EBE recognise how intersectionality (multiple overlapping social cate-
gorizations that may produce disadvantage) complicates the application of evi-
dence-based guidelines?
● How can EBE ensure that patient (student)-based evidence is not subsumed in
a knowledge hierarchy?
● How will EBE refuse the pressures and harms created by benchmarking in relation
to evidence-based practice?
Rcts are a much critiqued aspect of EBM
Critiques of the dominance of RCTs and their resulting guidelines are central to the
contested nature of EBM. Even in medicine the RCT carries a particular heft, but doctors,
who are more exposed to big pharma and other medical industries than teachers, are
aware that most RCTs are performed for the benefit of industry (Ioannidis 2016) not
patients. RCTs are understood not as determining ultimate truths, but as producing facts
that are always already loaded with theory (Greenhalgh 1999), which unfortunately is not
acknowledged and explored. They are also coloured by bias and ideology. Expert clin-
icians know that guidelines based on evidence from RCTs must be considered with

‘scepticism’ (Greenhalgh 2018, 6). Sackett, the founding father of EBM, established for
doctors how circumspect they must be in its application by insisting that they ask:
Were the patients in this trial sufficiently similar to the patient in front of me (in whatever
key respects) that I can safely apply the findings in this case’. . . ‘if not, piss on it’. (quoted
in Greenhalgh 2015)
By this he means that the doctor should use clinical judgement to decide whether to
apply the guideline to a patient who may be quite different from those in the trial.
Doctors are also aware that a large part of medical research simply does not inform
guidelines. For example, research which does not provide favourable outcomes for
funders may not be published. Rigid adherence to an evidence-based model means
that poor evidence often has to suffice (Govert, Hans, and Nijhof 2003), with resulting
deficiencies in patient care. RCTs deliberately and appropriately simplify, to try to
establish a simple form of cause and effect. Yet most patients are much more compli-
cated than those recruited and screened for trials. Caring for geriatric patients, for
example, when most RCTs are conducted on younger people, means working in a forest
of inappropriate guidelines. Doctors acknowledge the limitations of guidelines as being
valuable only for certain populations. RCTs also tend to assume greater life expectancy
as their desired outcome, whereas geriatric patients, for example, may well have
different needs and priorities, such as quality of life (Govert, Hans, and Nijhof 2003).
The solution to this, however, is not to conduct ever more RCTs on different popula-
tions, but as Greenhalgh says, to use evidence more circumspectly.
Instead, EBM is evolving, attempting to move away from earlier insistence (post-
Sackett) that RCT-based evidence should trump all other evidence, to a re-valuation of
individualised evidence from patients and patient-focused practice, and to case-based
studies; this shift recognises that early EBM contained inherent biases against the
patient (Greenhalgh 2015). Educators need to note this carefully, as this shift is towards
the kinds of evidence traditionally valued in education prior to the arrival of a ‘medical’
approach.
Yet this change in EBM faces the challenge of the bullying effects of RCTs, critics of
which claim it to be ‘perpetuated by the arrogant’ (Sackett et al. 1996, 71). RCTs
produce evidence that may be ‘presented in ways doctors and patients do not under-
stand’ (Howick 2014) and also serve to ‘buttress eminence-based claims to prestige’
(Ioannidis 2016, 83) made by gurus. This is another clear danger in education, already
noted in relation to particular evidence-based programs and their initiators (Eacott
2017; McKnight and Whitburn 2018).
Clinicians risk being labelled ‘unscientific’ (Tonelli 1998, 1239) if they value other forms
of reasoning and may fear litigation (Howick 2014). The ‘apparent rigor’ (Greenhalgh 2018,
2) of RCT-based guidelines pressures clinicians to comply. By doing so, they develop a kind
of brute moral authority in stark contrast to the sophisticated moral reasoning of the skilled
practitioner, with the result that moral freedom is restricted and discomfort created
(Govert, Hans, and Nijhof 2003). This has been similarly noted when teachers are forced
to implement mandated change in contradiction to their intuitive impulses (Adoniou
2012).
Part of the bullying effect of RCT-based guidelines is their burgeoning number, such that
they are both ‘unmanageable and unfathomable’ (Greenhalgh, Howick, and Maskrey 2014,

2). Research has demonstrated that 3679 pages of national guidelines were related to
hospital patient care in one unit over 24 hours (Greenhalgh, Howick, and Maskrey
2014). Clinicians and patients are potentially tyrannised when clinical management is
‘inappropriately driven by algorithmic protocols, top-down directives and population
targets’ (5). With the best interests of students at heart, educators need to heed these
warnings of the ways evidence-based practice can be misused.
● How will policy seek to transparently foreground the ‘crude’ (Greenhalgh 2018, 2)
limitations of RCTs while also suggesting their potential benefits?
● How will EBE ensure education remains student-centred, when EBM has been
identified as involving specific threats to patient-centred practice (Greenhalgh,
Howick, and Maskrey 2014)?
● How will EBE enshrine the principle of starting with the patient (student), not the
guideline (Greenhalgh 2015)?
● How will EBE ensure that practitioner expertise is not trumped by ‘appeals to data’
(Tonelli 1998, 1234)?
● How will EBE ensure that RCT-based evidence remains servant rather than master
(Greenhalgh 2018) in relation to teachers?
● How will teachers retain and/or acquire the authority to regard RCT type evidence-
based guidelines with scepticism, and indeed, as Sackett (cited in Greenhalgh 2015)
advises, to piss on them if they are deemed irrelevant?
● How will EBE uphold the maxim that ‘evidence can never directly dictate care’
(Tonelli 1998, 1239).
● How will EBE limit the glamourizing and fetishizing of ‘hard’ data, and model
respect for diverse forms of evidence?
EBM invites substantial conflict of interest
Adherents of positivist EBM are said to ‘do anything to make us all believe that EBM works’
(Govert, Hans, and Nijhof 2003, 465). Not coincidentally, there has been ‘insufficient
consideration of problems related to financial conflicts of interest’ (Fava 2017, 3). Even
those supportive of entrepreneurship in medicine advise that RCTs and meta-analyses have
been hijacked to ‘produce outcomes desirable for industry’ (Ioannidis 2016, 83). EBM
involves evidence that is ‘flawed, out of date, conflicted and suffering from publication bias’
(Howick 2014), yet this evidence is routinely considered to be gold standard. It is known
that ‘even studies with identical parameters have opposing results’ (Greenhalgh 2015) and
that tiny effects can be misleadingly presented as having larger impact (Howick 2014) to
serve particular interests. Drug and medical devices industries now set agendas by mis-
appropriating and distorting evidence (Greenhalgh, Howick, and Maskrey 2014) rather
than responding to doctors’ and patients’ needs.
Considering these serious vulnerabilities, EBM now seeks to uphold the individual
clinician’s judgement, based on a wide range of evidence including: intuition; tacit knowl-
edge; clinical expertise; patient perspectives; reflection on in-depth case studies; heuristic
reasoning; collaborative knowledge; awareness of context and practice philosophies such as
shared-decision making (Greenhalgh, Howick, and Maskrey 2014, 3). Again ironically, this

sounds very much like what Australian teachers do in their everyday work, pre-EBE. This is
now in danger of being subsumed beneath the requirement to follow the yellow brick gold
of RCTs and meta-analyses to find ‘what works’, a crude and universalist concept that has
been robustly critiqued in education literature (see for example Biesta 2007) as dogma and
yet upheld by some as a kind of anti-intellectual banner. ‘What works’ for some is not
necessarily ‘what works’ for others, no matter what RCTs may find.
● In EBE, how will teachers, as the experts in and leaders of their profession, set
agendas for research, or collaborate with students, parents and communities to set
them?
● How will EBE manage the enormous vulnerabilities of evidence-based practice to
conflicts of interest? How will these be identified and communicated to school
communities and to the public?
● How will EBE support teacher innovation and student-centred practices such as
the negotiation of the curriculum and pedagogy with students, when these are
counter to the interests of other stakeholders? These include publishing companies
who would prefer teachers to purchase scripted evidence-based programs and who
peddle compliance with dominance as professionalism.
● How will EBE, through policy language and principles, recognise teacher work as
creative synthesis rather than implementation?
● How will EBE ensure that the evidence claim in its title is fully understood by all
stakeholders to include and value all forms of evidence?
● How will EBE ensure that those with conflicts of interest do not undermine teacher
professionalism to serve their own financial aims, particularly through co-opting
hard data to authorise and validate their marketing and professional learning
programs?
● How will EBE eschew ‘what works’ for more complex, nuanced and better
informed ways of thinking about teaching and learning?
Discussion: so much to learn
When Greenhalgh (2015) asks whether EBM is ‘broken’, she concludes that this is an
irrelevant question. Instead, she wants doctors to ask ‘is the management of this patient
in these circumstances an appropriate (real) or inappropriate (rubbish) application of
the principles of EBM?’ She notes that after a generation of research into EBM, it
remains ‘mired’ (Greenhalgh 2018, 6) in problems identified decades ago, in particular
the enforcing of compliance with dubious evidence that has little relevance to an
individual patient’s narrative and context. There is evidence that an integrative and
patient-centred approach has better outcomes for patients (Greenhalgh 2015).
Yet how can this be openly debated in education, considering the silencing effects of
epidemiological medical discourse for doctors, let alone for teachers? How do educators
avoid the early mistakes of EBM, when ‘naïve and opportunistic’ (Grol 1997, 42)
application may have precluded deeper intellectual engagement with the challenges
suggested here? How can educators avoid practitioner wisdom being obliterated by top-
down managerialism?

We return to the uncritical adoption of the epidemiological model in education.
Considering the extent of the medical literature, which we have only been able to touch
on here in the form of a journal article, it would appear that this must be deliberate and
serve other purposes. Research to establish why the medical ‘evidence-base’ of contested
EBM has been ignored by policymakers is necessary and urgent. We hypothesise that the
epidemiological model serves to establish domination and control of teaching as
a feminised profession (Apple 1986), so that teachers are easily conscripted to provide
numerical evidence of ‘progress’ for systems. This model also serves a broader policy
agenda of centralising control and reducing teacher autonomy (Rowe and Skourdoumbis
2017) through an ‘uncritical ̶ and almost religious-like̶ belief in the unwavering power of
data, metrics and evidence’ (3).
This model, sourced from outside teachers’ comfort zones, also serves to keep them
‘ontologically insecure’ (Ball 2003, 220) and saps the confidence and solidarity required
for resistance. It is extraordinary to consider that RCTs, having been little used in
education, and with few educators in Australia having expertise in this methodology
(Moss, cited in Productivity Commission 2016b, 219) should suddenly be touted as the
gold standard for research in education. This is not a change instigated by the profession.
It may be easy for policymakers to find superficial claims that all is well with EBM to
counter our argument. For example, Stephen Margolis’ editorial claims that EBM is
‘undisputed’ and that patients are its ‘certain beneficiaries’ (Margolis 2018, 325) which
is demonstrably incorrect. As yet another irony, some of the best research into the
efficacy of EBM uses qualitative research methods such as autoethnography that would
be de-valued in the Australian government’s proposed evidence hierarchy (Productivity
Commission 2016b). Greenhalgh’s (2018) autoethnographic study of her own serious
injury and dangerous, RCT-based treatment is an example.
Yet practitioners of research methods such as autoethnography have been publically
vilified as ‘self-absorbed c**t[s]’ (Campbell 2017), demonstrating the gendered bias and
misogyny reserved for those practising ‘soft’ science. Real men, it is said, ‘do not collect
soft data’ (Gherardi and Turner 1987, 1). Yet when, as might be predicted, top-down
guidelines for EBE, despite their claim to bottom-up input, are not followed, only
qualitative research will be able to find out why. It seems no coincidence that ethno-
graphy should be denigrated just as it has been specifically identified as a research
approach that urgently needs to be mobilised to help societies understand the symbolic
violences of quantitative data cultures (Kitchin 2014).
We argue that the failure to genuinely engage with the literature around EBM
constitutes a fetishizing of medical power by educators and policymakers; they lust
after white-coated precision and absolute authority, while failing to understand that
medicine is much more complex than this. Undergraduate medical students, on the
other hand, are taught to have a highly critical and nuanced understanding of EBM,
considering the range of often conflicting guidelines available, and to weigh up the
advantages and disadvantages of any advice.
Medical students completing Monash University’s fourth year Evidence Based Medicine
task, for example, are rewarded for identifying why the care of patients with complex needs
and chronic illnesses should not necessarily be in alignment with guidelines. Medicine is
understood as a profession dealing with uncertainty, and often involving clinical equipoise
(Freedman 1987), which is the state in which there is no irrefutable basis for making clinical

choices, amidst the morass of doctor belief and experience, patient values and needs,
diverse evidence, trials and guidelines. Equipoise recognises that often, a ‘best way’ or
a ‘what works’ simply does not exist. Education has conveniently failed to engage with this
complexity in medicine.
The industry-driven medical guideline ‘factory’ (Ioannidis 2016, 82) creates as many
problems for doctors as it solves. Even when guidelines are produced by independent,
non-industry funded organisations, problems can result. In relation to asthma, for
example, a common disease with straightforward management goals, at least four
conflicting sets of guidelines re which drugs to use have led to confusion and a sub-
industry dictating how to work with contradictory advice
Curtis et al., in a recent UK-based ‘hot topics’ course for general practitioners
conclude that as a result of these publications ‘we now have guidelines that compete
in several key areas and ultimately less clarity on how to optimally manage asthma than
we had before’ (2018, 244). The idea that medical-style research will have the answers to
‘what works’ for education is, quite simply, a fiction. Medical research based RCTs and
meta-analyses cannot always answer, in a straightforward way, ‘what works’ for med-
icine. Medical guidelines are always changing, always being contradicted and updated,
always serving different interests.
Even Professor John Hattie, global purveyor of meta-meta-analyses for education,
admits that his research is just one ‘explanatory story’ (Hattie 2009, 22) and that one of
its key limitations is that it includes only quantitative data (Hattie 2009). His research,
carrying the weight of datified and medicalised mystique, has been implemented in
ways more like Govert, Hans, and Nijhof (2003) rigidity than rigor, such that Hattie has
now distanced himself from these endeavours, and even from the term ‘evidence-based’,
which he now perceives to denote a lack of critical thinking (see Knudsen 2017, 256).
The danger of policy creating ‘cookbook’ (Sackett et al. 1996, 72) teachers, who will
teach to the guideline as well as to the test has already been mapped by medicine.
Meanwhile, Hattie’s statistical method has been critiqued as pseudo-science (Bergeron
2017), highlighting the dangers of teachers having to implement policy based on
statistical manoeuvres they are not qualified to evaluate.
Hattie has also run into trouble with his medical examples, which he uses to bolster
the validity of small effect sizes. He cites the example of aspirin preventing heart attacks
in healthy people, giving statistics that lead to his conclusion that taking aspirin ‘sounds
worth it to me’ (2009, 9). This does not, however, take into account the harms that
taking aspirin can induce, which include serious gastrointestinal bleeding and haemor-
rhagic strokes. While there was a vogue for advising healthy people to take aspirin, it is
now believed that the harms outweigh the benefits (Baigent et al. 2009).
Hattie’s ‘truth’ is revealed as a limited and quickly outdated meta-analysis ‘fact’ that
does not take into account the more complex picture, which was already emerging at
the time he was writing: the study cited above was published in the same year he used
aspirin as an example of a scientifically validated intervention. Statistics, when used
uncritically, potentially cause harm. How will teachers be positioned in this numbers
game? How many students will have to ‘take aspirin’, based on some effect size, before
new statistics prove this to be harmful? Educational practice must be based on much
more than ever-changing RCTs and meta-analyses. In medicine, over five years,
fifty percent of guideline recommendations are overturned by new evidence (cited in

Glasziou, Del Mar, and Preston 2017, 6). A comparable situation in education would
create unimaginable turmoil for teachers.
Conclusion: recommendations for further research
Despite noting that hierarchies of quality in evidence are ‘contested’ (Productivity
Commission 2016b, 76), the Australian government’s Productivity Commission report
into establishing an evidence base for education concludes:
The commission supports investment in high quality research, particularly randomised
controlled trials in tandem with process evaluations, to further develop the Australian
education evidence base on what works best (2016, 212).
Yet even process evaluations of RCTs, which do offer some hope, have yet to be proven
to adequately account for context and complexity (Connolly, Keenan, and Urbanska
2018, 16).
Taking all that we have explained above into account, it is vital for the Australian
government and all other systems, in developing policy in this area, to move towards
a fuller and more consistent understanding of the benefits and costs of evidence-based
practice. Rather than removing teacher agency and enforcing subordination to data-
based cults (Eacott 2017), EBE needs to embrace a wide range of evidence. This is to
acknowledge that all research acts, including those purporting to be ‘science’, are social
acts (Harding 1986) and that data are never neutral, but are always framed ‘economic-
ally, ethically, temporally, spatially and philosophically’ (Kitchin 2014, 23). There are
always interests at work in data.
Rather than privileging RCTs, governments need to fund much needed research that
seeks conceptual and philosophical approaches to understanding data (Kitchin 2014)
and sets out to ascertain how practitioners successfully integrate a range of evidence to
inform their work (Tonelli 1998). As in medicine, RCTs need to form a vital but not
dominant component of the evidence teachers interpret. This process itself needs to be
understood as much more than the Productivity Commission’s much used ‘application’
and ‘implementation’, in relation to evidence.
Mere deference to science is no substitute for actually engaging with the literature
that shows EBM itself to be a contested and evolving field that is, ironically, trying to be
more ‘educational’ in its approaches, for example by valuing patient narratives and
perspectives, and intimate case studies. There is no pure, superior version of scientifi-
cally produced truth in the form of the RCT or meta-analysis, as medicine well knows.
EBM has not yet fixed the problems it set out to solve (Greenhalgh, Howick, and
Maskrey 2014), despite decades of trying.
There is no excuse for education to continue to pretend that this superior truth, and
a matching, neat, statistical evidence-based solution exist. Sackett and colleagues
warned at the outset that EBM ‘is not restricted to randomised controlled trials and
meta-analyses’ (1996, 72); failure to recognise the limits of these ‘may lead to unex-
pected and untoward consequences’ (Tonelli 1998, 1235). A sophisticated understand-
ing of medicine posits it as ‘more like casuistry than science’ (1239), as ‘moral knowing,
a narrative, interpretive, practical reasoning’ (Hunter cited in Greenhalgh and Hurwitz
1999, 50) not the uncritical application of RCT-based evidence. The latter is considered

to be ‘only a restrictive interpretation’ (Fava 2017, 3) even of a scientific approach to
clinical practice. The educational community needs energetic and robust debate around
the best ways to incorporate RCT-based evidence into practice, as instigated by
Greenhalgh in relation to medicine.
We hope the insights developed in this article serve to demonstrate how genuine
interdisciplinary dialogue can inform policy analysis. While we recognise that we
ourselves each belong to heterogeneous disciplines, and that we are not representative
voices, our generative sharing of discipline-specific literature and theory attempts to
‘explain phenomena, craft solutions [and] raise new questions’ (Mansilla and Gardner
2003, 3). More of this kind of complementary critical dialogue is needed in the process
of any cross-disciplinary policy translation of concepts and initiatives. In this instance,
for example, we have identified how risks such as the perpetuation of sexist and racist
ideologies through scientism accompany uncritical adoption.
In the field of education, teachers work with multiple cultural fictions, with their own
stories and values, and those of their students, parent body, school, communities and
discipline to design rich, meaningful and effective learning experiences. For policy-
makers to judge and portray this complex, creative and highly personalised work as in
deficit and in need of positivist medical intervention, is to misrepresent this highly
skilled profession. The rationale for such a judgement seemingly lies with an agenda to:
de-professionalise teachers for the purposes of centralised control; gain political advan-
tage through the manipulation of data and, perhaps most dangerously, to enable the
service of vested interests that has blighted evidence-based medicine. This is an agenda
that is hostile to teachers and students, and ultimately to the health of education.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributors
Dr Lucinda McKnight is a pre-service teacher educator and senior lecturer in pedagogy and
curriculum at Deakin University, Melbourne. She is also a qualified health and fitness professional.
She has a published track record of research in the use of scientific metaphor in education.
Dr Andy Morgan is a British Australian medical doctor and senior lecturer in general practice at
Monash University, Melbourne. He has an MA in Clinical Education from the Institute of Education,
UCL, London. His research interests are in consultation skills and patient-centred care. He is
a former fellow of the Royal College of General Practitioners, and current fellow of the Australian
Royal College of General Practitioners.
ORCID
Lucinda McKnight http://orcid.org/0000-0003-0997-6790
Andy Morgan http://orcid.org/0000-0002-6799-4797

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