Friday, April 01, 2016

Should evidence based medicine be declared obsolete?

Not in my opinion but there are some policy makers out there who think it should though they won't admit it. Some by implication even falsely invoke the idea of EBM to support their agenda. These are folks who favor top down control of medicine in order to diminish the decision making power of individual doctors and patients, as Retired Doc pointed out here.

They believe that variation is the enemy of health care (remember the Dartmouth Atlas?) and that such variation is driven by the autonomy of clinicians. An example of such thinking is this quote (via the Retired Doc post) from the book “New Rules” by Drs. Donald Berwick and Troyen Brennan:

"Today, this isolated relationship[ they are speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making."

EBM, some may be surprised to learn, is opposed to this type of approach.

Here's what some members of the EBM working group had to say in their seminal article in BMJ some years ago:

Evidence based medicine is not 'cookbook' medicine...External clinical evidence can inform, but can never replace, individual clinical expertise…

Clinicians who fear top down cookbooks will find the advocates of evidence based medicine joining them at the barricades.

Clearly this is in opposition to what the policy leaders are saying. It would lend clarity to the debate if they would just be honest and say they are opposed to EBM.

1 comment:

james gaulte said...

Great insight.The folks who favor the top-down approach to medical care are no friends of evidence based medicine and in fact it can get in the way of their desired hierarchal control.