Show Me the Way: There's More to Evidence-Based Medicine Than Meets the Eye. (Health)

Article excerpt

One of the most significant trends in medicine over the past decade has been the oddly named "evidence-based medicine movement". What, you might ask, were clinicians doing before, if not acting according to evidence? The arguments that have been waged over this issue have focused on the nature of evidence and the degree to which practice has been guided by the latest empirical finding of trials. That this should happen in the mid-1990s was not an accident. The increasing access to online scientific databases transformed the thinking of clinicians. Instead of accepting the previous pace of knowledge transfer, whereby the accumulation of evidence was eventually accepted as best practice and taught, evidence-based medicine calls on individual clinicians to search the electronic libraries and appraise the evidence that should be applied to their patients.

There were protests from the old school, and cries for the "art" of medicine to be preserved. But no one in their right mind could argue that medicine should not be conducted according to the best, and latest, evidence. But people like to be regarded as individuals, and medicine is not a science where hard and fast rules can be applied to inanimate objects. Take this treatment and you will be better. Have this operation and you will survive. Change your life like this and you'll avoid this problem. These may be commonly used invocations, but it is well known that patients use their own value systems to manage their medical problems. The mirage of certainty that evidence-based medicine portrayed seemed to ride roughshod over a problem that existed for many patients: that medicine cannot follow determinate patterns like physics or other laboratory sciences can.

What may be the best treatment for the average person (that is, as shown by the results of clinical trials) may not be best for the individual, even though the statistical odds might point in that direction. Patients were becoming more alert both to the uncertainty of medical processes and to the different options that were available.

Out of this cauldron of contesting world-views about medical practice -- old-school paternalism versus the empiricists of evidence-based medicine -- emerged another set of ideas: evidence-based patient choice.

Evidence-based patient choice aims to make two things explicit. First is the need to be crystal clear about the extent of evidence that exists, not just about the "best" course of action, but also about the pros and cons of what can be considered a legitimate range of options. Patients are often surprised about the levels of uncertainty that exist in medicine. One recent commentator stated that only 15-20 per cent of medical interventions had form proof of effectiveness. The second requirement of this evidence-based patient choice is to involve the patient in the tasks of understanding the probabilities of harms and benefits and realising that they have a responsibility to choose, or at least to contribute their views on the decision required.

Crudely put, decision-making between the clinicians and patient takes the form of three basic patterns: paternalism, informed choice and shared decision-making. Paternalism as a label has negative connotations: there is enormous potential for undermining patient autonomy and overriding unexplored individual preferences. …