Tensions between clinical autonomy and (IR)rationalist bureaucracy
practitioners are nowadays more likely to be exposed to the best evidence either directly or – more usually – through widely promulgated guidance.
Few would now dispute the principle that clinical practice should be based on the best available evidence, or that the basic principle of EBP is potentially beneficial to practice and hence to patient outcomes.
What can be wrong with systematically and explicitly reviewing and using all the
available evidence about the likely effects of alternative courses of action before
making a clinical decision? Moreover, can increasingly cash-strapped health systems
afford the waste that occurs when clinicians act idiosyncratically?) But there
have been many barriers to overcome, not least the defiance of clinicians, and
especially those who argue that the evidence is often impracticable, irrelevant or
absent, and takes too long to find. Knowledge, attitudes and beliefs have all played their part in
that resistance , as have the complexities of organizational behaviour . The knowledge
base both of individual clinicians and of the relevant sciences in general has
often been inadequate to sustain EBP; the attitude of clinicians has often been
one of wariness of the motives and competence of those producing guidance or
advocating changes to practice; and strongly held beliefs have undermined the use
of evidence. In one study of the implementation of EBP, for example, the senior hospital doctors believed that the guidelines on asthma and
glue ear did not apply to their specialized and complicated patients, while the general
practitioners believed that the guidelines did not apply to their mostly atypical
patients, and the junior doctors said they really didn’t have time to practise
evidence-based medicine (EBM) and anyway had to do as their bosses told them.
In short – at least in the 1990s when EBM was relatively new – all parties believed
that the guidelines applied to someone else but not to them. Catch-22. Yet the
direction of central policy is tending inexorably towards more protocol-driven
systems of care, exacerbating the potential tensions between clinical autonomy
and rationalist bureaucracy .
Even where there has been a willingness to adopt evidence and try to change
practice, organizational barriers such as inadequate resources or inappropriate
systems have provided further obstacles. For example, one might accept the
importance of scanning all patients who have had strokes, but what if the magnetic
resonance imaging (MRI) scanners are not available ? Perhaps
above all, practitioners have found that the science base is often not there when
they need it; that there are still large shadows of uncertainty where the evidence
is too insubstantial to justify a change in practice. That, indeed, is why there has
been such an increase in needs-led, service-oriented research whose aim is to produce
answers to the practical questions facing clinicians. Yet,
despite that increase, the landscape still seems full of grey areas and unresolved
questions . In sum, for all these reasons
and more, while there has been a reform in the way evidence is applied to practice,
the change is not nearly as radical or fundamental as the proponents of EBP
might wish.
First there was the gap between research and practice, encapsulated in the
persistent problem that, despite the massive efforts by the establishment – health
professions, research funders, educators, patient organizations, governments,
health commissioners, insurers and other payers – to promote EBP, clinicians still
so often seem to ignore research evidence in their daily practice. Second there
was the glaring disparity between the policy makers’ methods for trying to promote
EBP and what social scientists, philosophers, psychologists – and just about
anyone who studied such things – have long told us about the nature of knowledge
and how it gets used in the real world.
practitioners are nowadays more likely to be exposed to the best evidence either directly or – more usually – through widely promulgated guidance.
Few would now dispute the principle that clinical practice should be based on the best available evidence, or that the basic principle of EBP is potentially beneficial to practice and hence to patient outcomes.
What can be wrong with systematically and explicitly reviewing and using all the
available evidence about the likely effects of alternative courses of action before
making a clinical decision? Moreover, can increasingly cash-strapped health systems
afford the waste that occurs when clinicians act idiosyncratically?) But there
have been many barriers to overcome, not least the defiance of clinicians, and
especially those who argue that the evidence is often impracticable, irrelevant or
absent, and takes too long to find. Knowledge, attitudes and beliefs have all played their part in
that resistance , as have the complexities of organizational behaviour . The knowledge
base both of individual clinicians and of the relevant sciences in general has
often been inadequate to sustain EBP; the attitude of clinicians has often been
one of wariness of the motives and competence of those producing guidance or
advocating changes to practice; and strongly held beliefs have undermined the use
of evidence. In one study of the implementation of EBP, for example, the senior hospital doctors believed that the guidelines on asthma and
glue ear did not apply to their specialized and complicated patients, while the general
practitioners believed that the guidelines did not apply to their mostly atypical
patients, and the junior doctors said they really didn’t have time to practise
evidence-based medicine (EBM) and anyway had to do as their bosses told them.
In short – at least in the 1990s when EBM was relatively new – all parties believed
that the guidelines applied to someone else but not to them. Catch-22. Yet the
direction of central policy is tending inexorably towards more protocol-driven
systems of care, exacerbating the potential tensions between clinical autonomy
and rationalist bureaucracy .
Even where there has been a willingness to adopt evidence and try to change
practice, organizational barriers such as inadequate resources or inappropriate
systems have provided further obstacles. For example, one might accept the
importance of scanning all patients who have had strokes, but what if the magnetic
resonance imaging (MRI) scanners are not available ? Perhaps
above all, practitioners have found that the science base is often not there when
they need it; that there are still large shadows of uncertainty where the evidence
is too insubstantial to justify a change in practice. That, indeed, is why there has
been such an increase in needs-led, service-oriented research whose aim is to produce
answers to the practical questions facing clinicians. Yet,
despite that increase, the landscape still seems full of grey areas and unresolved
questions . In sum, for all these reasons
and more, while there has been a reform in the way evidence is applied to practice,
the change is not nearly as radical or fundamental as the proponents of EBP
might wish.
First there was the gap between research and practice, encapsulated in the
persistent problem that, despite the massive efforts by the establishment – health
professions, research funders, educators, patient organizations, governments,
health commissioners, insurers and other payers – to promote EBP, clinicians still
so often seem to ignore research evidence in their daily practice. Second there
was the glaring disparity between the policy makers’ methods for trying to promote
EBP and what social scientists, philosophers, psychologists – and just about
anyone who studied such things – have long told us about the nature of knowledge
and how it gets used in the real world.
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