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Evidence-based Medicine: Best Practice Or Restrictive Dogma

Evidence-based Medicine: Best Practice Or Restrictive Dogma

Sheridan Desmond J


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The concept of evidence-based medicine was launched in 1991 as a new paradigm to inform medical practice and has risen to be regarded as the gold standard. It rapidly gained the attention of medics, health service managers and the general media as it presented a means to improve efficiency and effectiveness of service delivery. Despite its stunning success in capturing the health agenda, the campaign that launched evidence-based medicine has also attracted criticism, particularly from clinicians and philosophers concerned about its selective views of knowledge and evidence, and for its denigration of reasoning, clinical experience and judgement.Evidence-Based Medicine traces this movement from its launch to its meteoric rise, examining what it has done for healthcare and medicine in the context of changes in science policy and the long-running criticism held against the movement for its inherent weaknesses.As evidence-based medicine will remain an important feature of healthcare in the decades to come, this book is perfect for healthcare professionals, medical scientists, health service managers and public health experts looking for a critical examination of the topic.

Table of Contents

Section Title Page Action Price
Contents ix
Preface vii
Chapter 1 The Origins of Evidence-Based Medicine 1
EBM: Brand New or New Branding? 1
EBM: The McMaster Model 3
Efforts to Build Medicine Based on Evidence from the 18th Century 9
Summary 14
References 15
Chapter 2 Evidence-Based Medicine in the UK 19
Thomas McKeown 19
Archie Cochrane 21
Summary 32
References 33
Chapter 3 The Cochrane Collaboration 37
Funding 39
Future Challenges 41
Mission Creep 43
Efficiency 43
Science or Market Research? 45
Is it Science? 46
The Tamiflu Saga 46
Summary 53
References 54
Chapter 4 Evidence-Based Medicine and the Evolution of Health Related Research 59
Historical Context 59
The Haldane Principle 60
Medical Research Council 62
Medical Research 63
The National Health Service (NHS) 65
Medical Progress, Increasing Complexity and Costs 66
Health Services Research 68
Medical Research and Health Policy 69
The Rothschild Report 70
Rothschild in Reverse 73
NHS Reforms 75
House of Lords Select Committee on Science and Technology 78
National Health Research Authority (NHRA) 79
The Rise of Health Services Research 80
The NHS R&D Programme and the Founding of EBM in the UK 82
EBM 84
Medical Research 86
Conclusions 87
References 89
Chapter 5 Hypothesis, Evidence, Knowledge and Reasoning in Medicine: Certainty and Uncertainty 95
Evidence in Medicine 97
Prophylactic Use of Anti-Flu Drugs Controversy 98
Best Evidence in Medicine 99
Hierarchies of Evidence — A Failed Enterprise 100
Evidence and Interpretation 101
EBM and Myth-Making Rhetoric 103
Clinical Judgement versus Mechanical Rules 105
Mechanical Rules and Public Health Screening 105
Diagnostic Criteria 108
Duckett Jones Diagnostic Criteria for Rheumatic Fever 109
The Role of Evidence in Clinical Judgement 110
Expert Opinion and Clinical Judgement 110
Mechanistic Reasoning and EBM 115
Mechanistic Reasoning and Clinical Medicine 117
Conclusions 119
References 120
Chapter 6 Evidenced-Based Medicine and Medical Science 125
Medical Science and Clinical Practice are Intimately Related and Interdependent 125
EBM: Impact on Science 127
Medical Science: Data Sets versus Hypothesis and Reasoning 129
John Snow’s Discovery of Water Borne Cholera: Truth is Richer than Myth 130
Data without Reason becomes a Fog 135
The Problem of Antibiotic Resistance 135
Contrasting US and UK Approaches 136
How Penicillin was Discovered and Developed 138
Meeting the Challenge; Then and Now 140
Problems Seeking Solutions versus Solutions Seeking Problems 143
Conclusions 146
References 147
Chapter 7 Impact of Evidence-Based Medicine on Clinical Practice: Achievements and Limitations 151
EBM: Impact of Medicine 152
Clinical Guidelines 154
National Institute for Clinical Excellence (NICE) 156
Impact of Guidelines in Clinical Practice 157
Wider Impact of EBM 158
Full Disclosure of Clinical Trials 158
Overdiagnosis in Medicine 159
EBM: Unintended Consequences 161
What Evidence? 162
Value of Evidence and Evidence of Value 162
Bias of the Easily Measurable 164
“Real EBM” — A New Iteration of EBM? 165
Conclusions 167
References 168
Chapter 8 Evidence-Based Medicine and Medical Professionalism 173
Evidence-Based Medicine (EBM) 176
Health Policy and Management 177
The Royal College of Physicians (RCP) 178
General Medical Council 181
Professionalism in Practice 183
EBM and Medical Professionalism 183
Evidence and Judgement 183
Guidelines, Rules and Clinical Judgement 184
Medical Professionalism in the Health Service 185
Clinical and Non-Clinical Professionalism and the Role of EBM 186
Medical Professionalism and Leadership 187
Conclusions 191
References 193
Chapter 9 The Future of Evidence-Based Medicine 197
Medicine is about more than EBM 198
EBM and Conflicting Professional Values 198
EBM Must be about more than Medicines 200
Independent EBM 202
EBM and Medical Science 203
EBM Replacing Clinical Science 203
EBM and the Language of Medicine 205
Overdiagnosis: Conceals more than it Reveals 206
Distortion of Meaning 207
Conclusions 211
References 212
Index 215