The History of Evidence-Based Medicine and Structural Diagnostic Failure.

Evidence-based medicine (EBM) was originally defined by Sackett and colleagues as the integration of external research evidence with clinical expertise and the circumstances of the individual patient. This article examines how the organizational conditions required to sustain that integrative model changed as healthcare became increasingly specialized, standardized, episodic, and administratively distributed. Historical developments in reimbursement, utilization management, institutional scaling, medical education, hospital-based care, documentation, and research design progressively made population evidence easier to classify and govern while dispersing responsibility for longitudinal and cross-system diagnostic synthesis. The result was not the conceptual failure of EBM, but the erosion of the clinical function required to determine whether external evidence applied to the patient and whether the diagnostic formulation remained valid as new information emerged. Structural Diagnostic Failure emerges as the historical consequence of this convergent transformation: evidence, consultations, tests, and treatments may continue to accumulate while no accountable role remains responsible for integrating them into a coherent and revisable diagnostic account. Restoring EBM in complex illness therefore requires more than improved evidence appraisal, patient-centered communication, or decision support. It requires structural protection of longitudinal responsibility for diagnostic convergence across specialties, institutions, and time.